All Cal Poly faculty, staff, and student research with human subjects, as well as other research involving human subjects that is conducted at Cal Poly, must be reviewed by the Cal Poly Human Subjects Committee for the protection of human subjects, the researchers, and the University. Human subjects research is defined as any systematic investigation of living human subjects that is designed to develop or contribute to generalizable knowledge. While the ethical guidelines for research are applicable to classroom activities, demonstrations, and assignments, the Human Subjects Committee does not review classroom activities unless data will be collected and used in a systematic investigation.

Researchers should complete all items on this approval form and submit three copies of it, along with three copies of a research protocol (containing the information detailed in the document Guidelines for Human Subjects Research Protocols), to the office of the current Chair of the Human Subjects Committee (Dr. Steve Davis, Bldg. 43, Rm. 353). Please feel free to attach an additional page if your responses to any of the items require more space. Your answers to the items on this form, as well as the research protocol, should be typed. The Committee will make every effort to respond to your submission within two to three weeks. Committee approval should be received prior to contacting prospective subjects and collecting data. Please read carefully Cal Poly's Policy for the Use of Human Subjects in Research prior to completing this application.

1. Date: _______________________________

2. Title of the research project: ______________________________________

__________________________________________________________

3. Type of research:

_____ Senior Project
_____ Master's Thesis
_____ Faculty research
_____ Other _______________________________________________
(Please describe)

4. Name(s) of researcher(s):

1. Principal Investigator: _________________________________________
   Department or Other Affiliation: __________________________________
   Phone: __________________
   E-Mail: _________________
   

   Position:
   

   _____ Faculty
   _____ Student
   _____ Other _________________________________________________
   

   (Please explain)

2. Additional Researcher: ___________________________________________
   Department or Other Affiliation: __________________________________
   Phone: __________________
   E-Mail: _________________
   

   Position:
   

   _____ Faculty
   _____ Student
   _____ Other _________________________________________________
   

   (Please explain)

3. Additional Researcher: ___________________________________________
   Department or Other Affiliation: __________________________________
   Phone: __________________
   E-Mail: _________________
   

   Position:
   

   _____ Faculty
   _____ Student
   _____ Other _________________________________________________
   

   (Please explain)

Any additional researchers involved in the project should be listed with the descriptive information requested above on a separate sheet.

5. Faculty Advisor, (if applicable): _________________________________

Department or Other Affiliation: __________________________________
Phone: __________________

Other thesis committee members if the research is a thesis:

1. ___________________________________
   Department or Other Affiliation: __________________________________
   Phone: __________________
   

2. ___________________________________
   Department or Other Affiliation: __________________________________
   Phone: __________________
   

3. ___________________________________
   Department or Other Affiliation: __________________________________
   Phone: __________________
   

6. Is there an external funding source for the project?

_____ Yes, and the source is:____________________________________
_____ No

7. Is this a modification of a project previously reviewed by Cal Poly's Human Subjects Committee?

_____ Yes, and the approximate date of last review was:__________________
_____ No

8. Estimated duration of the project:

Starting date: _____________ 2000
Completion date: _____________ 2000

9. Describe any risks (physical, psychological, social, or economic) that may be involved. See Specific Ethical Criterion #1 in Cal Poly's Policy for the Use of Human Subjects in Research for a description of the types of risks.
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10. Indicate what measures will be taken to minimize risks. See Specific Ethical Criterion #1 in Cal Poly's Policy for the Use of Human Subjects in Research for a discussion of strategies for minimizing risks.
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11. Explain how subjects' confidentiality will be protected. See Specific Ethical Criterion #5 in Cal Poly's Policy for the Use of Human Subjects in Research for a discussion of strategies for minimizing risks.
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12. Describe any incentives for participation that will be used. See Specific Ethical Criterion #2 in Cal Poly's Policy for the Use of Human Subjects in Research for a discussion of the use of incentives in research.
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13. Will deception of subjects be involved in the research procedures?

_____ Yes^*
_____ No

14. Type of review requested:

_____ Exempt from further review^*
_____ Expedited review
_____ Full review

See the section titled, "Types of Review" in Cal Poly's Policy for the Use of Human Subjects in Research for a discussion of the criteria for exempt, expedited, and full reviews.

*The research protocol submitted for a project presumed to be exempt may be abbreviated but should contain sufficient information to support the conclusion that the project meets the criteria for exemption.

15. Signatures:

1. Primary Researcher's Signature
   Your signature below indicates that the information presented in this application (the approval form and research protocol) is accurate and that you have read, understand, and agree to follow the guidelines contained in Cal Poly's Policy for the Use of Human Subjects in Research.

   _________________________		_________________________
   Name of Primary Researcher		Signature

2. Cal Poly Faculty Advisor's Signature (Required if this is student research)
   I have reviewed this research proposal which has been prepared by my advisee(s) in accordance with the Instructions for Obtaining Human Subjects Approval.

   _________________________		_________________________
   Name of Faculty Advisor		Signature

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