Columbia College Protection of Human Subjects (PHS) referral application form

Any survey or research project involving human subjects that is conducted by or for Columbia College students, faculty, administrators, staff, or members of the Board of Trustees and/or is conducted on Columbia College premises is subject to review by the College's Protection of Human Subjects Committee. If you are planning any such activity, complete this form and select 'submit,' and it will be forwarded to the committee for review.

PHS Committee at Columbia College

The committee's purpose at Columbia College is to examine and review surveys, experiments, studies, and any other research projects involving human subjects. The committee's goal is to insure that legal rights are not violate, that no one is harmed or compromised in any way by participation in a college-related study or survey, and to assure compliance with regulations formulated by the U.S. Department of Health and Human Services for the protection of human subjects in research. According to federal law, the committee must review any survey or study that (a) might identify respondents or subjects; (b) has sensitive topics such as illegal conduct, alcohol or drug use, sexual behavior, etc.; (c) might lead, if not kept confidential, to criminal or civil liability, or might damage the employment, academic standing, or financial standing of anyone identified or associated with the survey or study.

The Committee will evaluate your project using the following criteria:

Materials submitted to PHS Committee:

Description of project
Copy of Informed Consent is attached
Copy of instrument(s) attached
Contact information provided

Informed consent is sought by informing participants about the following:

Minimal description of the research
Risk and benefits to participants
Assurance of confidentiality
Freedom to refuse participation
Freedom to discontinue participation without penalty
How data will be used (publication, class project, etc.)

Please provide the following information

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Name Date

Position Student Faculty Administrator or other staff Board member Other

Class (course prefix, #, title) or organization/campus office for which you are conducting this project Instructor name(s) (if applicable) Date of project Location(s) of project Contact phone Contact email

Attach a description of your project, addressing questions regarding who will be surveyed or studied, how the project will be conducted, what will be done with the data you gather, and how confidentiality of participants will be maintained. This should be 1-2 paragraphs, separate from all other documents, and addressed to the Human Subjects Committee.

Description of project

Attach a copy of the instrument you will use in your study.

Copy of instrument for study

Attach the Informed Consent Statement to be used for your participants. You may model it after the sample Informed Consent Statement.

Informed Consent Form

Note: In most cases, reviews are handled within 10 business days. If, however, your project in any way involves manipulating subjects by altering behavior, thoughts, emotions, etc., or causes mental or physical stress for subjects, it will undergo further and more extensive review. Please see a committee member regarding evaluation materials and procedures. (Names of committee members are available from the Office for Academic Affairs.)