Application to Conduct Research
Application to Conduct Research
Name
Name
First
Last
School
Email
Phone
Phone
-
###
-
###
####
Purpose of Research
*
Stage of Study:
Stage of Study:
Piloting Procedures
Practicing Procedures
Identifying Possible Participants
Other
If Other, please describe
Do you have a completed IRB?
Do you have a completed IRB?
Yes
No
If Yes-- please attach:
Attach Files
Is IRB Letter from Department required?
Is IRB Letter from Department required?
Yes
No
Total number of children required for study?
*
Age of children to be used for study?
How many children need to have diagnosed special needs?
*
What prerequisite skills are required for this particular group?
What prerequisite skills are required for other children?
Is Teacher Participation Required
Is Teacher Participation Required
Yes
No
If yes, what is he/she required to do?
Target of Intervention
Days intervention will occur:
*
Days intervention will occur:
Monday
Tuesday
Wednesday
Thursday
Friday
Times of day intervention will occur
*
Length of each intervention session
*
Setting of intervention:
Setting of intervention:
In classroom
Outside of classroom (if approved, will need to complete Application to Reserve Space)
Setting of Intervention Additional Comments
Anticipated Target End Date:
Anticipated Target End Date:
*
/
MM
/
DD
YYYY
Date results will be shared with SGS:
Date results will be shared with SGS:
*
/
MM
/
DD
YYYY
Professor:
Professor:
First
Last
For more information, visit http://peabody.vanderbilt.edu/admin-offices/sgs/research.php