Forms - Community Engagement Review Board (CERB)

Name of Primary Investigator (Applicant)*

First Last

Is your project solely for a Wagner College course, with no expectation of communicating the findings outside of the course?*

I have no plans to use this project beyond a single college course.
This project is not an aspect of a course, or it is a component of a course that I might want to communicate beyond the college (through publication, presentation at a conference, posting on a website, or other forms of communication).
This project may be applied toward completion of the Honors Program, Departmental Honors, or a Master's degree.

Your project is exempt from CERB review.

Your project does not need to be reviewed by CERB. You do not need to complete this form. Please note that the full application form will appear only for applicants who indicate that the project may be used beyond a single course.

Is your project solely intended for internal evaluation of Wagner College as an institution, with no expectation of communicating the findings beyond Wagner College?*

Yes, this project is solely for institutional evaluation.
No, this project is not intended for institutional evaluation, or it is institutional evaluation that I might want to communicate beyond the college (through publication, presentation at a conference, posting on a website, or other forms of communication).

Your project is exempt from CERB review.

Your project does not need to be reviewed by CERB. You do not need to complete this form. Please note that the full application form will appear only for applicants who indicate that the project is for purposes beyond institutional evaluation.

Which of the following describes the primary focus of your project?*

Research originating from the Psychology Department
Research exploring educational practice or perceptions of education
Research focused on evaluations or perceptions of medical practice
Community-based research or research focused on service learning or civic engagement
Other

Your project should be reviewed by HERB, the Institutional Review Board (IRB) that evaluates community-based research.

Please submit your proposal to HERB, which uses a different application that is designed to evaluate experimental research or educational evaluation projects. Information about HERB can be found on their website. This form is not appropriate for your project.

Which of the following applies to your project?*

Sampling or manipulating body tissue (including blood)
Wound treatment
Any procedure for which a reasonable adult would seek physician advice
None of the above

Your project is not appropriate for CERB.

Please submit your project to an IRB with expertise in the area of your research. If you need approval from an IRB at Wagner College, either CERB or HERB will consider your project only after you obtain approval from an IRB with relevant expertise. Please do not complete this form until you have obtained approval from such an IRB.

Have you fully developed your proposed project, including your plan for informed consent (informed consent form) and decisions regarding all materials (questionnaires ready to be uploaded to this form, lists of specific interview questions, detailed descriptions of other materials)?*

Yes
Not yet

Do not complete this application until you are prepared to describe every proposed detail of your study, including informed consent and all materials (such as questionnaires and interview questions).

Date

Role of Primary Investigator*

As a researcher from outside the college, please seek permission to conduct your project from the Provost of Wagner College and submit that permission to the Chair of the Community Engagement Review Board. Please also complete this online application.

Name of Faculty Advisor*

First Last

Email of Faculty Advisor*

Names of Any Collaborating Researchers, Plus Institutional Affiliation If Not Wagner College

Investigator's Email*

Investigator's Phone

Academic Department

Title of Project*

Purpose of Project*

Title of Course

I believe participants in this study will be:*

at no greater risk than that associated with normal, everyday activities.
at greater risk than that associated with normal, everyday activities.

Does this research involve drugs or other controlled substances?*

Yes
No

Does this research involve payment of subjects for participation?*

Yes
No

Does this research involve access to subjects through a cooperating institution (outside Wagner College)?*

Yes
No

Does this research involve substances taken internally or applied externally to the subjects?*

Yes
No

Does this research involve mechanical or electrical devices (e.g., electrodes) applied to the subjects?*

Yes
No

Does this research involve fluids (e.g., blood) or tissues removed from the subjects?*

Yes
No

Does this research involve subjects experiencing stress (physiological or psychological)?*

Yes
No

Does this research involve deception of subjects concerning any aspect of purposes or procedures (misleading or withheld information)?*

Yes
No

Does this research involve subjects who would be judged to have limited freedom of consent (such as, but not limited to individuals who are children or adolescents under the age of 18, potentially undocumented immigrants, developmentally delayed persons, or those institutionalized)?*

Yes
No

Does this research involve any procedure or activities that might place the subjects as risk (psychological, physical, social, or legal)?*

Yes
No

Does this research involve use of interviews, surveys, questionnaires, audio or video recordings (below upload a copy of any copies of any structured instruments/forms or sample questions)?*

Yes
No

Is a copy of the consent form provided to the participant or the legally-authorized representative (e.g., parent) of the participant?*

Yes
No

Approximate number of participants to be involved in the research:*

Rationale and Specific Aims*

What is the goal and/or purpose of this study? (brief background and or context recommended). What are the intended areas of exploration?

Describe how subjects will be selected. Describe the connection between the goal (above) and the people involved in the project.*

Describe the project plan (with timeline)*

Upload copy of informed consent form (or informed consent statement)

For research with subjects under the age of 18, upload copy of assent form (or assent statement)

Upload interview questions or questionnaire

Additional File Upload

Describe any materials not attached.

If you plan to use any electronic data collection methods, please describe them here.

Data Sharing Plan*

Describe any likely or projected dissemination of your data or findings via verbal, visual, electronic, or other means. Describe your plans for sharing your data or findings with the research subjects (the community).

Describe potential risks greater than those associated with normal, everyday activities (or clearly state that potential risks will not be greater than those associated with normal, everyday activities).*

Include in this section a data management plan for protection of subject-specific information.

Describe safeguards (including informed consent, reassuring participants that they may leave the study at any time, allowing participants to skip any aspects of the study they choose, etc.).*

Describe any anticipated benefit to the subjects (or clearly state that there is no anticipated benefit to the subjects).*

Describe any other benefits of the proposed study.*

Certifications: I am familiar with the policies and procedures of the Wagner College Community Engagement Review Board (CERB) and with the principles of ethical treatment of human participants in research projects as set forth in the Belmont Report [i.e., respect for persons (acknowledging autonomy and protecting those with diminished autonomy), beneficence (maximizing possible benefits while minimizing possible harm), and justice (sharing equitably the burdens and benefits in the population)].*

Yes

I have informed all those who will work on this project of the Belmont Report principles.*

Yes

If substantive changes in the procedures involving participants become necessary, I will submit these changes for review before they are implemented.*

Yes

All information gathered or generated in pursuit of this project will be held in the strictest confidence. With the exception of communications within the research team identified in this application, no communications regarding this project will include any identifiable information about research subjects. In the event that the above described consent process provides subjects the opportunity to consent to the use of identificable information (such as, but not limited to, video recording or other documents), then all such information will be used solely in the manner to which was consented.*

Yes

Forms – Community Engagement Review Board (CERB)

Application for Review of Research Involving Community Engagement

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