MONTANA STATE UNIVERSITY
Institutional Review Board Application for Review
(revised 10/14/2011)

(click here for a link to MS Word doc)

Have you read the instructions? If not, return to the homepage and follow the link to the instructions and adhere to them. (Please use the MS Word doc form. If you use this form, delete the instructions prior to printing and submission.)
Beginning January 1, 2006, University policy requires that all protocols submitted from individuals NOT employeed by or students of Montana State University be charged a $500 review fee per application. Renewals for those proposals will be at no charge. Applications from private entities (i.e. projects not administered by MSU's Office of Sponsored Programs) will be charged the $500 fee per application. Renewals for those proposals will also be at no charge.
All investigators must complete the online training in the use of human subjects. Most investigators will need to choose the Behavioral Sciences Module. Use this link: Collaborative Institutional Training Initiative (CITI)
Please type your responses in bold. Do not use all capital letters.

THIS AREA IS FOR INSTITUTIONAL REVIEW BOARD USE ONLY. DO NOT WRITE IN THIS AREA.
Approved:: Approval Date:
Disapproved: IRB Chair's Signature:


Date:

I. Investigators and Associates (list all investigators involved; application will be filed under name of first
    person listed)

 

  NAME: TITLE:  
  DEPT: PHONE:  
  ADDRESS:    
  E-MAIL ADDRESS:    
    DATE TRAINING COMPLETED:   Required training: CITI training (see IRB website for link)  

 

  NAME: TITLE:  
  DEPT: PHONE:  
  ADDRESS:    
  E-MAIL ADDRESS:    
    DATE TRAINING COMPLETED:   Required training: CITI training (see IRB website for link)  

   (repeat for additional investigators if needed; or delete extra if not necessary)


Do you as PI, any family member or any of the involved researchers or their family members have consulting agreements, management responsibilities or substantial equity (greater than $10,000 in value or greater than 5% total equity) in the sponsor, subcontractor or in the technology, or serve on the Board of the Sponsor? _____ YES _____ NO. If you answered Yes, you will need to contact Pamela Merrell, Assistant Legal Counsel-JD at 406-994-3480.


II. Title of Proposal (please be sure this appears on the first page):
III. Beginning Date for Use of Human Subjects:
IV. Type of Grant and/or Project (if applicable)
    Research Grant:
    Contract:
    Training Grant:
    Classroom Experiments/Projects:
    Thesis Project:
    Other (Specify):
V. Name of Funding Agency to which Proposal is Being Submitted (if applicable):
VI. Signatures

Submitted by Investigator
    Typed Name:
    Signature:
    Date:

Faculty sponsor (for student)

    Typed Name:
    Signature:
    Date:


VII. Summary of Activity. Provide answers to each section and add space as needed. Do not refer to an accompanying grant or contract proposal.


  • F. Will an investigational device be used? (Yes or No. If yes, provide name, source description of purpose, how used, and status with the U.S. Food and Drug Administration FDA). Include a statement as to whether or not device poses a significant risk. Attach any relevant material.)


  • G. Will academic records be used? (Yes or No.)


  • H. Will this research involve the use of:


  •             If you answered "Yes" to any of the items under "H.", you must complete the HIPAA worksheet .   


  • I. Will audio-visual or tape recordings or photographs be made? (Yes or No)


  • J. Will written consent form(s) be used? (Please use accepted format from our website. Be sure to indicate that participation is voluntary. Provide a stand-alone copy; do not include the form here.) (Yes or No. If no, explain.)