Date:
Name of Project:

Principal Investigator:

Contact Person:

Academic Department:

Contact Address:

Contact Phone:

Contact E-mail:

Grant Administered at (mark one):
Waisman Center
Other UW-Madison Specify:
 Other – Specify:

Fund account to be billed:

University of Wisconsin Human Subjects Committee Protocol Number:


Approval Date:
Expiration Date:

PART II: SERVICES REQUESTED (Check all that apply)

Research with WECP children during school day
Recruitment of WECP children/families outside of class time
Renewal of previously approved request

PART III: INVESTIGATION SUMMARY

A. Complete this section only if you wish to conduct research with WECP children during class time

Number of Children requested:

Estimated total time required of each child (number of sessions, length of sessions):

Describe characteristics of children you wish to include or exclude (e.g., age, sex, special needs):

Number of parents required and estimated total time required of each parent:

Time frame for study, including start/completion dates, total number of sessions per day/week, etc.:

Indicate where research will take place:

List names of staff that will facilitate research with children and provide contact information:

Staff Member 1:
Name: Title/Position:
Birthday: Email:

Staff Member 2:
Name: Title/Position:
Birthday: Email:

Staff Member 3:
Name: Title/Position:
Birthday: Email:

Staff Member 4:
Name: Title/Position:
Birthday: Email:

B. Complete this section only if you wish to conduct research with WECP children outside of class time

Please submit a one-page summary of your project.  Please attach a copy of your research project’s IRB stamped consent form and letter to parents.

C. Complete this section only if you wish to renew / extend a previously approved service

Renewal request for research with WECP children during class time:

Are you continuing to use the same procedures exactly as previously described in the protocol of your original application?                  Yes         No

Would you like to continue to work with the same classroom that you are currently working with?                                                   Yes         No
                               
If you answered No to either of the above questions, please complete a new application.

If you answered Yes to either of the above questions, please provide information about staff who will be working with children.
                     

Contact RCP Staff at 263-5192 or rpc@waisman.wisc.edu if you have any questions.