Samples are for reference only

Submit forms to hsrlog@ithaca.edu

Standard/Expedited Application

Sample Application

Consists of: 

Cover Page/Checklist

Application - Before submitting, be sure to delete guidelines in red.  All numbered items must be included or application will be returned. 

Not complete without Cover Page/Checklist/Recruitment Statement/ Informed Consent Form and all Survey Instruments

 Exempt Application

Sample Application

 Consists of:

Application

Not complete without Informed Consent Form or Waiver of Informed Consent and all Survey Instruments

 Delegated Review - for faculty members only

Parameters for Delegated Review

Sample Application

 Consists of:

Application - for faculty member (same application as Standard)

Not complete without Cover Page/Checklist/Recruitment Statement/Informed Consent Form and all Survey Instruments

Project Summary Template (to be included with application packet - for your student's use)

Informed Consent Template (to be included with application packet - for your student's use)

Recruitment Statement (needed for ALL applications EXCEPT anonymous surveys):

Sample Recruitment Script

Sample Permission for External Recruitment Letter

For Anonymous Surveys ONLY:

Sample Tear-off Cover Page

Be sure to include Recruitment Statement with application packet

 Recruitment Statement - Blank Template

A Sample Tear-off Cover Page should be used in place of Informed Consent Form for anonymous surveys

Informed Consent Form (needed for ALL applications EXCEPT anonymous surveys)

Sample Informed Consent Form

Informed Consent Form - Template

Other forms

HIPAA Authorization -For use and disclosure of protected health information

Notice of Completion Form - after project is complete-please note that review/approval of future proposals is contingent upon submission of this form