MONTANA STATE UNIVERSITY
Institutional Review Board Application for Review
(revised 1/01/08)

(to download this form, click on file, save as, change file type to Plain Text [*.txt], rename your file, and you will be able to pull that file into MS Word, Word Perfect, or another word processing program -- OR -- click here for a link to MS Word doc)

[Include copies of PI's and Co-PI's "Completion Certificate(s)" as proof that all have received the education and instructions for researchers using human subjects.  The preferred instruction and education is that from the National Cancer Institute:   http:/Cancer.gov - Human Participant Protections Education for Research Teams/cme.cancer.gov/clinicaltrials/learning/humanparticipant-protections.asp 

Beginning January 1, 2006, University policy requires that all protocols submitted from individuals NOT employeed by Montana State University be charged a $500 review fee per application. Renewals for those proposals will be at no charge.

THIS AREA IS FOR INSTITUTIONAL REVIEW BOARD USE ONLY. DO NOT WRITE IN THIS AREA.

Approval Date:

Application Number:

SUBMIT 14 COPIES OF THIS APPLICATION (INCLUDING THE SIGNATURE COPY), ALONG WITH 14 COPIES OF THE SUBJECT CONSENT FORM AND 14 COPIES OF ALL OTHER RELEVANT MATERIALS, TO INSTITUTIONAL REVIEW BOARD, 960 TECHNOLOGY BLVD., ROOM 127, MONTANA STATE UNIVERSITY, BOZEMAN, MT 59717-3610.  (PLEASE STAPLE, BIND OR CLIP TOGETHER THE APPLICATION FORM, SURVEYS, ETC. AS 14 INDIVIDUAL PACKETS; ONE COMPLETE PACKET FOR EACH BOARD MEMBER.)  SUBMIT ONE COPY OF GRANT CONTRACT PROPOSAL FOR THE OFFICE FILE.  FOR INFORMATION AND ASSISTANCE, CALL 994-6783 OR CONTACT THE INSTITUTIONAL REVIEW BOARD CHAIR, MARK QUINN, 994-5721 or CHERYL JOHNSON, ADMINISTRATOR, 994-4706.

PLEASE TYPE YOUR RESPONSES IN BOLD

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:      

 

  NAME: TITLE:  
  DEPT: PHONE:  
  ADDRESS:    
  E-MAIL ADDRESS:    
    DATE TRAINING COMPLETED:      

 

  NAME: TITLE:  
  DEPT: PHONE:  
  ADDRESS:    
  E-MAIL ADDRESS:    
    DATE TRAINING COMPLETED:      

    (repeat if needed)

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 the Director of the Technology Transfer Office, Dr. Rebecca Mahurin at 406-994-7868.

 

II. Title of Proposal:

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:

THIS AREA IS FOR INSTITUTIONAL REVIEW BOARD USE ONLY. DO NOT WRITE IN THIS AREA.

Approved:

Disapproved:

HSC Chairman's Signature and Date:

Subject to the following conditions:

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



 

VIII. Checklist to be Completed by Investigator(s)