King’s College Institutional Review Board for Research Involving Human Subjects

EXEMPT FROM REVIEW: EDUCATIONAL ASSESSMENTSSection One: General InformationProject Title:Principle Investigator: Department:Phone: ( ) - Ext: E-mail: Alternative E-mail: Fax: ( ) - Mailing Address:

Funding Source: Not Applicable □ Internal □ External Agency : ___________________________

List any contractors, entities, or IRBs Associated with this project: Not Applicable □ 1- ________________________________________________________

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Section Two: Key PersonnelMy Signature below indicates the following:

1- I certify that all information provided in this application is complete and correct.2- I understand that as the Principle Investigator I am responsible to ensure that this study is

conducted in an ethical manner. By signing below, I signify that I have reviewed the conditions for which a study can be exempt from the Intuitional Review process and have met these conditions to the vest of my ability. At any time during the course of this study, if the nature changes and it becomes requisite that a IRB application is submitted, I will quit all research activities until IRB approval is attained.

3- I agree to comply with all applicable federal, state, and local laws.

Signature of Principle Investigator: ______________________ Date: ________ (Researchers may use an electronic signature or submit an additional hard copy in addition to the electronic copy that includes an original signature from the Principle Investigator)

Section Three: MethodologyProcedures: Describe how you will carry out the project in terms that are understandable to someone who is not familiar with your field of study:

Section Four: Educational AssessmentsIndicate True or False for the following questionsDeception will not be used. True FalseSubjects are not exposed to discomfort or harassment beyond levels experienced in everyday life. True False

We will not ask any question related to suicidal or homicidal ideation, intent, or plan. True False

Research involves the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior.

True False

Information is obtained /recorded in a way that human subjects cannot be identified directly or through identifiers linked to the subject. True False

No information will be disclosed that could reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employment, or reputation. True False

If participants are children, only educational tests and/or passive observation of behavior is used. Investigators will not interact with child subjects. If subjects are adults, tests, surveys, interviews, and behavioral observations may be included.

True False

An information letter is provided, but no formal written consent is obtained. True False

Subjects will not be accessed on a repeated basis. Except in the case of a focus group which may be considered open-ended interview permitting multiple contacts presuming that all other exempt conditions are met. True

False

If children are studied, investigators must provide a rationale for why a particular age range was selected, indicate their expertise in working with children, describe the adequacy of their facilities for pediatric research, and indicate whether they will have sufficient numbers of children to adequately address the research question. If this is necessary for your study, you have described this in the procedures section.

True

False

Copies of all measures are attached for IRB review True False

Section Five: FOR IRB USE ONLY: Do not write in this sectionDate Received: _____________Date of Review:_____________

Approved as exempt category □ Not approved as exempt for the following reason(s)□

1- ____________________________________________________________________________________________________________________________________________________________