1. Name of Primary Investigator:

   Phone:

   E-mail:

   Check all that apply:
   KCKCC Full-time Faculty
   KCKCC Adjunct Faculty
   KCKCC Full-Time Staff
   KCKCC Part-time Staff
   KCKCC Student
   
   Student elsewhere:
   Institution:
   
   Other:
   
   

   If student, name of faculty supervisor:

   Phone:

   E-mail:

2. Title of Project:

3. Please answer the following questions with regard to the research activity proposed:

   		YES	NO
   a.	Payment of subjects for participation?
   b.	Access to subjects through a cooperating institution?
   c.	Subjects experiencing physiological or psychological stress above a level that would be associated with their normal everyday activity?
   d.	Misleading or deceiving subjects about the purpose, procedure or any other aspect of the research?
   e.	Subjects who would be judged to have limited freedom of consent (e.g. minors, mentally retarded or ill, aged)?
   f.	Any procedures or activities that might place the subjects in psychological, physical, or social risk?
   g.	Subjects taking any substance internally or having any substance applied externally?
   h.	Subjects having mechanical or electrical devices applied (e.g., electrodes)?
   i.	Removing any fluids (e.g., blood) or tissue from subjects?

   
   If yes to any of the above questions, please explain.
   
   

4. Does the project involve any of the following:



		YES	NO
a.	Surveys or questionnaires? [If yes, attach copy.]
b.	Interviews?
c.	Audio recording?
d.	Video recording?

5. Describe the purpose of the project (Statement of problem).
   
   
   
6. Describe the proposed subjects—age, sex, race, or other special characteristics.
   
   
   
7. State the number of subjects and procedure for selecting them.
   
   
   
8. Describe the setting and location.
   
   
   
9. Describe procedure:
   
   
   
10. Describe methods of data collection.
    
    
    
11. Describe the methods of analysis of results.
    
    
    
12. Provide any additional information that may be important to understanding this research project.
    

Certifications

Electronic Signature Investigator

Electronic Signature
If student research, Faculty Supervisor