3. Consultant(s) contact information: 4. Do the investigators have a in this study? NO Skip to question 6. – YES Proceed to question 5. – 5. Has a been filed? NO Refer to . – YES Proceed to question 6 below. – 6. Do the investigators have any other known conflict of interest in this study? NO YES Please explain the conflict: – 7. Study Title: 8. Funding Source: Select one of the following options in the drop-down menu below. Sponsor-External Funds (Includes PRF, Kinley Trust and McCoy awards) Identify the Sponsor and grant/award number: Departmental Funding: Other Self-Funded: 9. Anticipated Duration of Study: Please indicate when this project will end (MM/YYYY) 10. Will the research expose participants to discomfort or distress beyond that normally encountered in daily life? NO YES This study is not eligible for exemption. Please complete a Non-Exempt Research Application. – 11. Could disclosure of the research reasonably place participants at participants’ responses outside risk of criminal or civil liability or be damaging to financial standing, employability or participants’ reputation? NO YES This study is not eligible for exemption. Please complete a Non-Exempt Research Application. – 12. Does any part of the research require deception or incomplete disclosure? NO
3. Consultant(s) contact information: 4. Do the investigators have a in this study? NO – Skip to question 6. YES – Proceed to question 5. 5. Has a been filed? NO – Refer to . YES – Proceed to question 6 below. 6. Do the investigators have any other known conflict of interest in this study? NO YES – Please explain the conflict: 7. Study Title: 8. Funding Source: Select one of the following options in the drop-down menu below. Sponsor-External Funds (Includes PRF, Kinley Trust and McCoy awards) Identify the Sponsor and grant/award number: Departmental Funding: Other Self-Funded: 9. Anticipated Duration of Study: Please indicate when this project will end (MM/YYYY) 10. Will the research expose participants to discomfort or distress beyond that normally encountered in daily life? NO YES – This study is not eligible for exemption. Please complete a Non-Exempt Research Application. 11. Could disclosure of participants’ responses outside the research reasonably place participants at risk of criminal or civil liability or be damaging to participants’ financial standing, employability or reputation? NO YES – This study is not eligible for exemption. Please complete a Non-Exempt Research Application. 12. Does any part of the research require deception or incomplete disclosure? NO
Exempt-6%20Form%20v1-13%20unprotected.docx