Research Review Committee – Become an approved Research Site Agency Application Form Agency InformationAgency Name(Required)Phone(Required)Email(Required) Website Address(es) of Location(s) where research will take place:Address Line 1Address Line 2CityStateZIP Add RemovePopulation CharacteristicsNumber of individuals served by Agency:Age-Range of ClientsIs there a primary diagnosis of clients? If not, please describe the range of diagnoses treated.Personnel InformationCEO/Director First Last Number of BCBAs employed by agencyStaff member designated as Research Coordinator at Agency: First Last Credentials/Licensure if applicableThis field is hidden when viewing the formResearch Background (HIDDEN)Highest level of education achievedHigh School/GEDSome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreePhDResearch Background (describe the research experience of the research coordinator)(Required)Nomination of agency employee willing to serve in the future on the RRCGuidelines and RegulationsHuman Rights training in regards to human subjects in research must be completed by all who are conducting research. Which human rights training will be used for researchers at your organization?Types of behavior-analytic research that will be conducted by the agency: Add RemoveOtherDoes your agency treat clients overseen by DMH-DD programs?(Required) Yes No Does your agency have a Human Rights Committee?(Required) Yes No Is your agency accredited through any other governing bodies? (CARF, BHOCE, ect…)(Required) Yes No Please list the governing bodies:(Required) Add RemoveAre you aware that any principle investigator or data collector must complete a human services training prior to conducting research and provide proof of completion to the RRC?(Required) Yes No Are you aware that each project proposal will need to be approved by either the CEO / Director / or supervisor within the agency before submitting to the RRC?(Required) Yes No Note: In the event that the agency’s research coordinator is no longer employed by the agency or the agency wishes to place a new individual in this role, the agency must submit a new application to the RRC specifying the person who will assume the research coordinator role. The RRC will review the agency application and let the agency know in writing whether or not the application has been accepted. Agencies are allowed to resubmit the application based on the feedback provided.
