PIMA COMMUNITY COLLEGE
APPLICATION FOR HUMAN SUBJECTS REVIEW
In completing the following application, be advised that the person(s) reviewing it may be entirely unfamiliar with the field of study involved. Present the request in TYPEWRITTEN form and in nontechnical terms. It is the investigator's responsibility to give information about research procedure that is most likely to entail risk but not to express judgment about the risk. Please submit a copy of your complete proposal, an informed consent/assent form as subjects will view it, any other material or background information that will assist the review, and a curriculum vitae or biographical sketch. 

THE COMPETE LIST OF REQUIRED MATERIALS IS AT THE END OF THIS TEMPLATE
******************************************************************************************** PRINCIPAL INVESTIGATOR:__________________________________________________________________ ADDRESS: DEPT./OFFICE:____________________________________________________________________ 

DAYTIME PHONE:(________)___________________ 	EMAIL____________________________________ 	
PIMA COMMUNITY COLLEGE EMPLOYEE: 	CAMPUS:_____________ MAIL CODE:________ 	
DATE OF  REQUEST:___________________________ 		
TYPE OF REVIEW: 	NEW	 ( ) 	RENEWAL  	( ) 	
If RENEWAL, are there any substantive changes? 	Yes ( ) 	No ( ) 	

BUILDING:_______________________________________________________________________ ORGANIZATION:__________________________________________________________________ STREET/PO BOX:__________________________________________________________________ CITY:________________________________ STATE:______ ZIP CODE:___________________ 

PROJECT TITLE:_____________________________________________________________________________ 
ANTICIPATED DATA COLLECTION PERIOD: FROM:___________________ TO:____________________ 
MONTH/YEAR       MONTH/YEAR 

NAMES AND AFFILIATION(S) OF CO-INVESTIGATOR(S) (IF APPLICABLE): ________________________ 
IS PROJECT SUPPORTED BY RESEARCH GRANT(S)? YES ( ) NO ( )
IF YES, list Funding Source(s):_________________________________________________________ 
Funding Amount(s) (total or per-capita): _________________

1.	GENERAL PURPOSE OF THE RESEARCH:

2.	BRIEF RATIONALE AND BACKGROUND (INCLUDING REFERENCE TO THEORETICAL FRAMEWORK):

3.	DATA TO BE OBTAINED BY (check all that applies): 
a.	Paper Questionnaire ( ) 
b.	Online Questionnaire
c.	Telephone Questionnaire ( ) 
d.	Individual Interview ( ) 
e.	Group Interview ( )
f.	Focus group ( )
g.	Observation ( )   
h.	Experiment ( ) 
i.	Secondary Source  ( ) 
j.	Other (specify):________________________________________

4.	PROJECT DESCRIPTION: 
The reviewer (s) must have sufficient information, nontechnical and detailed, about what will happen with/to subjects to evaluate/estimate the risks. Assurance from the investigator, no matter how strong, will not substitute for a description of the transactions between investigator and subject. If a questionnaire is used, attach a copy. (When visual or auditory stimuli, chemical substances, or other measures might affect the health of subjects, a statement from a qualified person or other appropriate documentation will aid in evaluating the nature of any risk created. In questionable cases, the reviewers will require such documentation.)  
[Summary of Methodology] 

5.	DESCRIPTION OF SUBJECTS

Will subjects be LESS than 18 years old?  Yes ( )   No ( )   Age _____to_____ 

How many subjects are expected to participate?

Male ( ) Female ( ) Minority (  )
 
Will subjects be students at Pima Community College? 
Yes ( ) No ( ) 
Will subjects be employees of Pima Community College? 
Yes ( ) No ( )

6.	How will subjects be selected, enlisted or recruited? 
Please, note that Pima Community College does not provide any student or employee individual information to third parties. Printed Information materials can be distributed on campus only with campus administration authorization. Instructional time cannot be used for recruitment purposes with exception of the research directly related to the curriculum. 

7.	How will subjects be informed of procedures, intent of the study, and potential risks to them? 
Please, note that the informed consent form should be submitted with the application, as well as any printed material and scripts of oral explanations.

8.	What steps will be taken to allow subjects to withdraw at any time without prejudice? How will subjects be informed that their participation is voluntary and that they may withdraw from the study any time they wish to discontinue participation? 
Please, note that the informed consent form should be submitted with the application, as well as any printed material and scripts of oral explanations.

9.	How will subjects' privacy be maintained and confidentiality guaranteed?  How will data be recorded (notes; audiotapes; videotapes; self-administered instrument), stored (paper form; electronically), and kept secure? How long will data be kept and how will it be destroyed?  Where will informed consent forms be stored?  Will data be used for purposes other than this study? 
Please, note that Pima Community College requires to indicate limited (and no more than six) number of years when identifying data will be kept.

10.	Does the research require the use of PCC resources? If yes, please, list.
Please, note that Pima Community College usually does not allow to use its resources for third party research. 
-	Facilities (classrooms, labs,…)
-	Staff and faculty time and effort (to administer the tests during class time, to compile background student data, etc.) 
-	Other
-	Does the research require the use of PCC resources? If yes, please, list.

11.	Will the research require data sharing agreement between PCC and the tier organization? Does this organization have the data sharing agreement with PCC already? 

12.	Please be aware that all information gathered through your human subjects project is subject to Pima's Data Classification Policy that can be found here: https://www.pima.edu/about-pima/leadership-policies/policies/index.html
We require all approved projects to adhere to these standards.

Will you adhere to Pima's Data Classification Policy? YES____NO

13.	Do you plan to publish your research? YES____NO
Please be aware that we require that in the case you decide to publish your research, the institution identity will not be revealed.
Will you reveal the institutional identity if you decide to publish your research? YES____NO

REQUIRED ATTACHMENTS: (please, check the documents that you are submitting with this application)
Curriculum Vitae or biographical sketch of the principal investigator ( )
College informed consent form 

If applicable:
Questionnaire ( )
Interview outline ( ) 
Verbal script ( )
Site authorization — Pima Community College ( ) 
Site authorization — other location ( )
Confidentiality statement ( )
Information flyers and other printed materials ( ) 
Assent form as child subjects will view it ( )
Other documentation (list, please): 

******************************************************************************************** In making this application, I certify that I have read and understand the Policies and Procedures for Research Projects with Human Subjects, and that I intend to comply with the letter and spirit of the Policy.  Significant changes in the protocol will be submitted to the College for written approval prior to these changes being put into practice.   
SIGNATURES: 
__________________________________________________			____________________
Principal Investigator 							Date 
Department Chairperson (if Pima Community College Faculty Member)	 

Name and department: ____________________________________________________________________

Signature: ___________________________________________________     Date: ____________________	

Faculty Advisor (if thesis or dissertation research) Institution 			
Name and position: ________________________________________________________________________

Institution: _______________________________________________________________________________

Signature: ___________________________________________________     Date: ____________________	

******************************************************************************************** Please return to: Office of Strategy, Analytics and Research (STAR)
E-mail: research@pima.edu 
Intercampus Mail Code: 1275 
Mailing Address: Room 212, Building C Pima Community College District Central Office 4905C East Broadway Boulevard 4905C East Broadway Boulevard Tucson, AZ 85709-1275 Tucson, Arizona 
Telephone Number:  (520) 206-4934 FAX Number: (520) 206-4754 
Adopted by Pima Community College, 2003. Revised January 2020.