Research/Project Application

The Moog Center for Deaf Education

Where Deaf Children Talk

Research/Project Application

Research conducted at the Moog Center or involving Moog Center staff, students, and/or families must undergo review and be approved before it may begin. The Research Review Committee meets monthly and will respond to your request following review. Thank you for your interest.

Date:

Month Day Year

Principal Investigator:

First Name Last Name

Affiliation:

Title:

E-mail:

Phone Number:

Area Code Phone Number

Contact information, if other than PI:

Name:

First Name Last Name

Title:

E-mail:

Please indicate reason for this request (check all that apply):

Interested in Collaborating Dissertation Thesis Subject Recruitment Class Requirement* Capstone* Honors Project*

*Attach syllabus (if applicable) and provide the following:

Instructor/ professor/ supervisor's name:

First Name Last Name

E-mail:

Phone Number:

Area Code Phone Number

______________________________________________________________________________________________

Will Moog staff be engaged in this research? (for guidance on engagement see http://www.hhs.gov/ohrp/policy/engage08.html)

Yes No

If Yes, please specify name:

What is the project timeline? Describe when it is proposed to start and finish:

Where will the research take place?

At the Moog Center for Deaf Education Offsite Other

If offsite, where?

If other, please specify (phone, mail, email, etc.):

Has protection of human subjects training (e.g., CITI, NIH, other) been completed by all engaged investigators?

Yes No

If yes, please attach copy of certification and modules completed:

Has HIPAA training been completed by all investigators?

Yes No

If yes, please attach copy of certification and modules completed:

Briefly describe proposed research/project in lay language (do not cut and paste from your protocol/grant):

If IRB Approval has been received, please attach approval letter:

If IRB Approval has not yet been received, please complete the following as applicable:

If you have applied, but it is not yet been received, please list where and when you applied:

If you have NOT yet applied, but plan to, where and when do you plan to apply?

If the project is exempt, who made that determination?

If the project is not human subject research, who made that determination?

Was Moog included in IRB application recruitment plan?

Yes No Not applicable

All applications must include complete research protocol or grant proposal, IRB application (include any modifications/continuing reviews, etc.), consent forms, recruitment documents/script, survey instruments, or other pertinent documents to support your application.

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