Principal Investigator (PI) or Project Faculty Advisor: (NOT a student or fellow; must be a WPI employee) E-Mail Name: Tel No: Address: Department: Co-Investigator(s): (Co-PI(s)/non students) E-Mail Name: Tel No: Address: E-Mail Name: Tel No: Address: Student Investigator(s): E-Mail Name: Tel No: Address: E-Mail Name: Tel No: Address: Check if: Undergraduate project (MQP, IQP, Suff., other) Graduate project (M.S. Ph.D., other) Has an IRB ever suspended or terminated a study of any investigator listed above? No Yes (Attach a summary of the event and resolution.) The proposed research will involve the following (Check all that apply): Vulnerable Populations: pregnant women human fetuses neonates minors/children prisoners students individuals with mental disabilities individuals with physical disabilities Collaborating Institutions: (Please list all collaborating Institutions.) Locations of Research: (If at WPI, please indicate where on campus. If off campus, please give details of locations.) Project Title: Funding: (If the research is funded, please enclose one copy of the research proposal or most recent draft with your application.) Funding Agency: WPI Fund: Human Subjects Research: (All study personnel having direct contact with subjects must take and pass a training course on human subjects research. There are links to web-based training courses that can be accessed under the Training link on the IRB web site . The IRB requires a copy of the completion certificate from the course or proof of an equivalent program.) Anticipated Dates of Research: Start Date of End Date of Research: Research:
Principal Investigator (PI) or Project Faculty Advisor: (NOT a student or fellow; must be a WPI employee) Name: Tel No: E-Mail Address: Department: Co-Investigator(s): (Co-PI(s)/non students) Name: Tel No: E-Mail Address: Name: Tel No: E-Mail Address: Student Investigator(s): Name: Tel No: E-Mail Address: Name: Tel No: E-Mail Address: Check if: Undergraduate project (MQP, IQP, Suff., other) Graduate project (M.S. Ph.D., other) Has an IRB ever suspended or terminated a study of any investigator listed above? No Yes (Attach a summary of the event and resolution.) Vulnerable Populations: The proposed research will involve the following (Check all that apply): pregnant women human fetuses neonates minors/children prisoners students individuals with mental disabilities individuals with physical disabilities Collaborating Institutions: (Please list all collaborating Institutions.) Locations of Research: (If at WPI, please indicate where on campus. If off campus, please give details of locations.) Project Title: Funding: (If the research is funded, please enclose one copy of the research proposal or most recent draft with your application.) Funding Agency: WPI Fund: Human Subjects Research: (All study personnel having direct contact with subjects must take and pass a training course on human subjects research. There are links to web-based training courses that can be accessed under the Training link on the IRB web site . The IRB requires a copy of the completion certificate from the course or proof of an equivalent program.) Anticipated Dates of Research: Start Date of Research: End Date of Research:
WPI%20IRB%20Exemption%20Application%20Form-060412.docx