Complete the table below. (LR: Lead Researcher, FS: Faculty Sponsor, CR: Co-Researcher, RP: Research Personnel) Include additional rows for study team members as needed. If there is a Faculty Sponsor, s/he must be listed below (even if s/he is not engaged in research), as s/he must be identified to provide oversight and guidance to the Lead Researcher. Indicate whether the study team member will be involved in the following research activities. Personnel who are not interacting with participants for research purposes and/or who do not have access to identifiable private information or identifiable biospecimens (e.g., statisticians) are not engaged in human-subjects research and therefore should not be listed below. Role Name, Title & Degrees Department & UCI Affiliation - Faculty, Staff, Graduate or Student Recruit Informed Consent Process Interact with Participant Access Participant Identifiable Information / Biospecimen Analyze Participant Identifiable Information / Biospecimen LR <Type here> <Type here> N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No FS <Type here> <Type here> N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No CR RP <Type here> <Type here> N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No CR RP <Type here> <Type here> N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No CR RP <Type here> <Type here> N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No CR RP <Type here> <Type here> N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No SECTION 3: WHAT IS YOUR RESEARCH QUESTION? State the hypothesis or primary objective of the research. Include a rationale for conducting the study. [Maximum length = 250 WORDS] <Type here> SECTION 4: SUBJECT POPULATION Complete the table below. Include additional rows for subject category/group, as needed.
Procedure and/or the Data Collection Instrument Is the Procedure/ Instrument already being completed as part of a program evaluation or an educational activity? Is the Procedure/ Instrument a standardized measure? List the frequency and the time required for participants to complete the Procedure/ Instrument Describe the setting where data collection will take place Confidentiality: Are participant identifiers (IDs) recorded during data collection? EXAMPLES: ABC Satisfaction Survey via Amazon Turk (delete this example row) N/A Yes No N/A Yes No Survey will be completed 3x during the academic year. Takes no more than 20 mins. to complete Amazon Mechanical Turk No IDs Code with link to IDs Yes IDs Interview regarding Academic Life (delete this example row) N/A Yes No N/A Yes No 2x at the beginning and end of the academic year A place convenient for subject (e.g. coffee shop) No IDs Code with link to IDs Yes IDs <Type here> N/A Yes No N/A Yes No <Type here> <Type here> No IDs Code with link to IDs Yes IDs <Type here> N/A Yes No N/A Yes No <Type here> <Type here> No IDs Code with link to IDs Yes IDs <Type here> N/A Yes No N/A Yes No <Type here> <Type here> No IDs Code with link to IDs Yes IDs <Type here> N/A Yes No N/A Yes No <Type here> <Type here> No IDs Code with link to IDs Yes IDs <Type here> N/A Yes No N/A Yes No <Type here> <Type here> No IDs Code with link to IDs Yes IDs Will any of the study procedures include collecting photographs, audio recordings and/or video recordings? N/A – No photos, audio or video recordings will be taken. Photos, audio or video recordings will be taken. Text regarding the photos or recordings will be included in the consent document and specific permission to record identifiers will be obtained from participants. Check one of the following: Facial image will be in video or photo Participants’ names will be collected or recorded in either video, photo or audio recording Collecting photographs, as well as audio and video recordings will be optional for the participant Other: <Type here> SECTION 9: CONFIDENTIALITY OF RESEARCH DATA