Form A
Request for Institutional Review Board (IRB) Clearance
(Please complete the form in its entirety. Do not say "see attached")

Primary Researcher

Name:___________________________________	Email:______________________________
Mailing address: ________________________________	City:_________________________
State:______	Zip:__________________	Phone:____________________________________
Names of Additional Researchers for this study:

Thesis/Dissertation Director (or other research sponsor,). Required if primary researcher is not a DSU Employee

Name: __________________________________	Email:______________________________
Mailing address:_________________________________	City:_________________________
State:______	Zip:___________________	Phone:____________________________________

Title of Research:

Brief description of basic research questions:

Briefly describe the subjects (age, ethnicity, and other relevant demographic information):

Describe how subjects will be recruited and any other incentives for participation:

Start date of research:			Completion date of research:
If human subjects are involved:
Anticipated date of first contact with participants:
Anticipated last date of contact with participants: 

Identify all sources of funding:

Agreement to follow IRB procedures. My signature below indicates that I understand and agree to adhere to relevant principles and ethical responsibilities expected by my profession. I have attached: l. Informed Consent Statement and, 2. copies of the surveys and questionnaires that I will be using in this research project. I understand and agree to adhere to general principles required for the protection of human subjects. I agree to immediately report any incidents, major irregularities, and major changes in this research to the IRB Chair. I agree to request a Continuing Review from the IRB if the research is still in progress 12 months after the start date shown above.

Signed:___________________________________	Signed:_____________________________________
		Primary Researcher					Research Sponsor

Date:_____________________________________	Date:_______________________________________

Send to: Dan McFall, PhD, IRB Chair; PO Box 3217, Delta State University, Cleveland, MS 38733
Phone: 662-846-4395	                   Fax: 662-846-4869		Email: dmcfall@deltastate.edu