Application for Departmental Review
Missouri State University
Protection of Human Subjects
Application for Departmental Review
Principal Investigator (Faculty) ________________________________________________________
Project Title ______________________________________________________________________
Co-Workers (designate faculty/student) _________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Submit a complete copy of your University IRB Application with this form.
I hereby agree to conduct this study in accordance with the procedures set forth in my project description, to uphold the APA Ethical Principles, and to report to the committee any outcomes or reactions to the experiment which were not anticipated in the risks description and might influence the committees decision to sustain approval of the project.
_______________________________ _____________________________
Principal Investigator (faculty) Experimenter (e.g., graduate student)
_______________________________ _____________________________
Date Experimenter
______________________________
Experimenter
________________________________________________________________________
Date: __________________
Approved: ___________________________
Withheld: ___________________________
Signature: __________________________
(Chairperson)