Project Proposal Submission Form Research Review Committee Project Proposal Step 1 of 3 33% 1. Has your agency been approved as a research site by the RRC?(Required) Yes No Date of Approval MM slash DD slash YYYY Date of Application MM slash DD slash YYYY Responsible Project Investigator(Required)Phone(Required)Email(Required) Primary Work Location(Required)(Example: Specific clinic, residential home)2. TrainingCITI TrainedPHRP TrainedOther human rights trainingList out nameDate MM slash DD slash YYYY 3. Additional Investigator (if applicable)PhoneEmail LocationAdditional Data CollectorsTitle of Project 4. Nature of the Research and Expected Benefit5. Anticipated Duration of the ProjectFrom MM slash DD slash YYYY To MM slash DD slash YYYY Note: Any research project that continues for longer that 1 calendar year requires that an application be submitted for renewal.6. Is It a Request for Renewal? Yes No Note: If “Yes” please attach the original proposal and committee approval form plus 1 copy of this proposal and proceed to question number 20.Max. file size: 10 MB. 7. Is This Project Receiving Funding? Yes No By What Organization?8. Type of research participant (included all that apply). Indicate the approximate number in each category. Adult without developmental diagnosis (18 years or older)Agency employee (18 years or older)Special population (e.g. prisoner, pregnant, disabled)(specify including age & #)Minor not otherwise specified (less than 18Other(specify including age and #)9. Recruitment of Participants (Check all that apply) Unpaid agency volunteer Unpaid non-agency volunteer Paid agency volunteer Paid non-agency volunteer Parent or guardian of child served at Agency Sibling of child served at Agency Individual served at Agency Other (Please specify) Other10. Expected Participant Compensation (check all that apply) No compensation Financial compensation Other (please specify) OtherSpecify $ Rate11. Location of the Research (check all that apply) Main campus Additional agency site Agency off-campus residential facility Off-campus Other Specify siteNote: If off-campus locations are included, please attach a signed permission form from a responsible individual (e.g. business owner, school superintendent, principal) for each locationMax. file size: 10 MB. 12. Will the participants be exposed to more than minimal risk? Yes No If "Yes" Please Elaborate13. Attach copies of consent and assent procedures.Max. file size: 10 MB. Consent forms are required if more than minimal risk is involved. Both consent and assent forms are required for any research involving minors. Please see http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html (refer to 46.101.) 14. Describe the procedure(s) used to ensure that participants are aware of their right to refuse to participate in the study, of the behavior they will be asked to engage in, any possible discomfort they may experience, and of their right to withdraw from the study at any time.15. Confidentiality and anonymity of information obtained (check all that apply) Participant’s responses will be anonymous. (Data are collected in a way that no one (including the researcher) can identify the individual associated with any particular result of response, e.g., a survey with no names or other identifying information). Participant’s responses will be confidential. (Records are maintained in a way that ensures only the researchers have access to any information or results linked to a specific individual). Other (Please specify) OtherExample: Results will be shared with the participant’s clinical team and parents, where applicable. 16. Does the research involve the use of deception? Yes No If "yes" please elaborate in the space below, describing the deception used and providing a justification of the need of deception.17. Does the research involve debriefing of participants? Yes No If “yes” please provide an explanation in the space below describing how (e.g. spoken, with written statement) and when the participant will be debriefed. If “no” please provide an explanation of why debriefing is not necessary.18. Is the proposed research consistent with the Belmont Principles and the American Psychological Association’s ethical principles concerning research with human participants? Yes No 19. In the space below, please provide a brief description of the methods to be employed in the research including a description of the participants and how you plan to recruit them, the materials to be used, and the research procedures.20. In the space below, please provide a brief description of where and how the data from the study will be store, who will have access to them, and how long the data will be retained.21. Are you applying for an exemption? Yes No Note: If “yes” please submit the Exemption Code # in the space below, citing your specific reason. For a listing of reasons, go to http://www.hhs.gov/ohrp/humansubjects/guidance/45crf46.html (Refer to 46.101.)22. Upload Consent Form and CertificationsMax. file size: 10 MB. I certify that I have read the Belmont Principles (http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html) and the American Psychological Association’s ethical principles concerning research with human participants (http://www.apa.org/ethics). I will adhere to the policies and procedures explained therin. Should changes in the procedure or consent form described below (or in related documents) become advisable, I will submit them to the RRC for approval. I understand that the responsibility for the ethical conduct of the study rests with the responsible project investigator. I agree to report any participant’s complaints that may arise to the RRC. Consent(Required) I agree to the above statement(Required)Responsible Investigator’s Signature(Required)Date(Required) MM slash DD slash YYYY Investigator’s Signature (if different)Date MM slash DD slash YYYY All other data collectorsDate MM slash DD slash YYYY YOU MAY NOT BEGIN CONDUCTING ANY ASPECT OF THE PROPOSED STUDY UNTIL SUCH TIME AS YOU HAVE RECEIVED WRITTEN APPROVAL FOR THE PROPOSAL