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Being a small college without a long history of active research, Hampden-Sydney has a human subjects research review committee that considers cases as they arise on campus.  The following form is submitted to the committee for approval, which is usually done within a couple of business days.  The College does not have additional written guidelines above and beyond the following form.


Hampden-Sydney College 


Human Subjects Research Review Committee 



Investigator Summary Description of Research Involving the Use of Human Subjects 



Submission Date:  ­­­­­­­­­­­­­­________________                Proposed Start-up Date: ____________ 


Investigator’s Name:  _____________________________________________________ 


Project Title: ____________________________________________________________ 


Department: ___________________________Phone:  ________________________ 


This research is being conducted for: 


_____________Undergraduate Course ________________________________________ 

                                                               (Course name/number) 



                                                            (Faculty Advisor) 


_____________Faculty Research 


Granting Agencies: 



I hereby certify that upon approval of this proposal by the human subjects committee, no changes will be made without approval of the HSRC, and that any problems, adverse reactions, or unforeseen conditions encountered in the use of human subjects will be immediately reported to the chair of the HSRC. 



Electronic Signature: _____________________________     Date: _______________ 


I. Project Description 


Briefly describe the objectives of your research, data collection procedures, the need for human subjects, and any special conditions or procedures for their involvement. You need not be lengthy but please provide enough information for the Review Board to assess the risks to which your subjects may be exposed and the benefits likely to result from your proposed experiment(s). 


II. Characteristics of the Subject Group(s) 


Describe the characteristics of the group(s) to be used. Specify particularly if human subjects are either children, mentally incompetent, or from a legally restricted group. For each statement, indicate the page number in the proposal where substantiating documentation can be found. 


a) Gender, race or ethnic group, age range, etc.: 


b)  Affiliation of subjects (e.g., college students, elementary school children, hospital patients, general public, etc.): 


c)  Subjects’ general state of health (mental or physical): 


d)  The necessity for using these particular groups: 


e)  Briefly explain how subjects will be recruited. Describe the procedure to the point of gaining consent. 


f)  Explicitly describe what the subjects will be asked to do. 



III. Risks to Subjects 


Describe in detail any physical, psychological, social, legal, economic, or other risks you can foresee both immediate and long range. For each statement, indicate the page number in the proposal where substantiating documentation is found. 


a)  Immediate risk: 


b)  Long-range risk: 


c)  Rationale for the necessity of such risks: 


d)  How will the risks be minimized? 


e)  If the risks have been identified, briefly describe the importance of knowledge to be gained and explain why you feel that the value of the information to be gained outweighs the risks. 


IV. Confidentiality of Data 


What precautions will be taken to safeguard identifiable records of individuals? This question applies if you are using secondary sources of data. Be specific about the long-range and immediate use of data by you and others. 


V. Consent Procedures 


Federal regulations require precautionary measures to be taken to insure the protection of human subjects on physical, psychological, social, and other issues. This includes the use of  “informed consent” procedures as described in the institutional guidelines. 


a)  How will the subjects be informed of the nature of the investigation, the reasonably foreseeable risks, and the voluntary nature of his/her participation? 


            ___________in writing                                               _______________orally 


b) Once the above information has been presented, will you obtain written consent from the subjects (i.e., their signature) prior to their participation? 


            _____________Yes (attach a copy of the informed consent form) 


_____________No (identify the reasons for requesting a waiver of the written consent requirements) 


c)  If the subjects are minors ______________, or mentally incompetent _____________, describe how and by whom permission will be granted. 


_________________________________________              _____________________ 

Signature of Primary Investigator                                           Date 


VI. The Use of Deception 


If deception is to be utilized in your project, you must describe in detail the circumstances which you feel justify the use of deception. In particular, specify the nature of the deception, how and when the subjects will find out about the deception, and explain precisely the nature of your debriefing procedures. 


a)  At any point in your procedure, will it be necessary for you to use deception? 


b)  Briefly explain the rationale for using deception in this project. 


c)  Explicitly describe your debriefing procedure. 


d)  How long after the experimental session will subjects be debriefed? 


e)  If debriefing is not done immediately, at which point will subjects be made aware of the deception in the experimental session? 





IRB Administration Approved, Standard Consent Form  




Hampden-Sydney College 



Research Project Title 



Investigator’s Name, Course and Course Number, Telephone Number 



You have been asked to participate in a research study that is being conducted by a Psychology major at Hampden-Sydney College. The purpose of this study is to examine  




The purpose of the study, terms of your participation, as well as any expected risks and benefits, must be fully explained to you before you sign this form and give your consent to participate. 


You should also know that participation in research is entirely voluntary. You may refuse to participate or may withdraw from participation at any time without jeopardy to future medical care, education or employment status, or other entitlement. 


The investigator may withdraw you from participation at his/her professional discretion. 


If, during the course of this study, significant new information which has been developed during the study becomes available, which may relate to your willingness to continue to participate, this information will be provided to you by the investigator. 


Any information derived from this research project which personally identifies you will not be voluntarily released or disclosed without your separate consent, except as specifically required by law. 


If at any time you have questions regarding this research or your participation in it, you should contact the investigator or his/her assistants who must answer your questions. 


If, at any time, you have comments regarding the conduct of this research or if you wish to discuss your rights as a research subject, you may contact Dr. __________  _________, the advisor to this research project at (804) 223 -  --------. 


You will be given a copy of this consent form to keep. 


I consent to participate in this study. 



Signature of Subject (age 18 and older)                                     Date 



Signature of Investigator                                                          Date 

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Do you know if you can have a consent form waived? You can still have students consent, but it would not have to involve a form.
Posted 19:33, 23 Jul 2014
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