Please type narrative responses to the items below.  Please be as descriptive and reflective as possible when typing your responses and provide sufficient description to support your application for exemption in light of the criteria in Section VI.A of the JSCC-IRB Policy.  All items require a response- use N/A for those that are not applicable to your request.

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* 1. State your research objective/purpose, research question(s) or hypotheses.

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* 2. Include a statement as to any possible benefits to participants.  If none, state so.

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* 3. State any possible risks to the participant, and if any are present, explain whether you believe the requests are more than minimal, and if applicable, how you intend to mitigate or minimize these risks.  If no foreseeable risks exist, state so.

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* 4. Is this research conducted in established or commonly accepted educational settings that specifically involve normal educational practices that are not likely to adversely impact students’ opportunity to learn required educational content or the assessment of educators who provide instruction. Explain.

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* 5. Is this research conducted in established or commonly accepted educational settings that specifically involve normal educational practices that are not likely to adversely impact students’ opportunity to learn required educational content or the assessment of educators who provide instruction. Explain.

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* 6. Is this research that includes only interactions involving educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures, or observation of public criteria? If the answer is “yes,” explain and proceed to items 7 and 8.

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* 7. Is the information recorded in such a manner that the identity of the human subjects cannot be readily ascertained, directly or through identifiers linked to the subjects?

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* 8. Would any disclosure of the participants’ responses outside the research reasonably place them at risk of criminal or civil liability or be damaging to their financial standing, employability, educational advancement, or reputation?

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* 9. Is this research involving benign behavioral interventions in conjunction with collection of information from an adult subject through verbal or written responses, or audiovisual recording of a subject who prospectively agrees to the intervention and information collection? If the answer is “yes,” explain and proceed to items 10 and 11.

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* 10. Is the information recorded in such a manner that the identity of the human subjects cannot be readily ascertained, directly or through identifiers linked to the subjects?

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* 11. Would any disclosure of the participants’ responses outside the research reasonably place them at risk of criminal or civil liability or be damaging to their financial standing, employability, educational advancement, or reputation?

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* 12. Is this secondary research within the definition of Section VI.A.(d) of the Procedures? If yes, explain using the criteria in Section VI.A.(d).

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* 13. List any incentives and/or costs beyond daily life, if applicable.

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* 14. How will you be using subjects in your study? Will you be observing human subjects, interviewing human subjects, or distributing a questionnaire to individuals or groups of individuals?

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* 15. Please explain the process through which you will obtain informed consent.

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* 16. How will subjects be selected (randomly or non-randomly)? What type of sampling technique will be used?

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* 17. Include a statement about guaranteeing anonymity and/or confidentiality. Address how you intend to communicate the results of the research to the participants of the study.

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* 18. Explain where the collected data will be stored, for how long, and who will have access to it.

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* 19. Please sign (type) your name:

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