To be completed by IRB:
PROTOCOL # _____
Minimum Risk _____
Expedited Review _____

[SAMPLE]

PROTOCOL APPROVAL APPLICATION
INSTITUTIONAL REVIEW BOARD
CALIFORNIA STATE POLYTECHNIC UNIVERSITY, POMONA

[Many thanks to Professor Janine Riveire for permission to post this sample.]

All relevant sections of this application must be completed and submitted electronically to the Office of Research and Sponsored Programs. Email to kagruber@csupomona.edu
All applicants need to provide evidence of passing the NIH tutorial on Human Participant Protections for Research Teams before a protocol can be activated. The tutorial can be accessed at
http://cme.nci.nih.gov/intro.htm. The Certificate of Completion should be printed and a copy faxed to the Research Office (869-2993).
If you have questions concerning the completion of this form, please read the sheet "Directions for Completion of Human Subjects Protocol Approval Application" or contact Dr. Kenneth Gruber, Director, Research and Sponsored Programs (909-869-2954). In all cases, no research may proceed on or off campus until authorized by the Institutional Review Board.

DATE SUBMITTED: 24 May 2002
NEW __X_ or RENEWAL of Protocol #_

TITLE OF PROJECT/PROTOCOL:
Assessing Attitude Change and Self-confidence of Future Teachers toward Arts Integration in the Curriculum

RESPONSIBLE FACULTY MEMBER:
Name: Janine Riveire
College and Department: Letters, Arts, and Social Sciences; Music Department
Campus Phone Number: XXXX

DECLARATION BY RESPONSIBLE FACULTY MEMBER:
This research is guided by the ethical principles regarding research involving human subjects set forth in the Belmont Report.
Signature of Responsible Faculty Member: ____________________________________

This protocol has been reviewed and approved by the Institutional Review Board, California State Polytechnic University, Pomona
________________________________
David Adams, Ph.D., Chair, IRB / Date

I. SUBJECTS

A. What is the number of Human Subjects to be used in your research?
+/- 120
B. Briefly describe the subject population.
Students currently enrolled in Liberal Studies 420, and students who are currently enrolled in or have completed LS 421
C. Will the subjects be compensated? If yes, how?
NO
D. Describe the control group(s), if any.
None

II. RESEARCH

A. Purpose (State the relationship of the proposed research to previous scientific investigations in the field.)
A stated objective of the 420 class is to develop student skills and self-confidence in the different arts (music, dance, theater, visual art). An unstated objective for the course is to shape student attitudes so they intend to include arts instruction in their future classrooms. I wish to measure or track the development of these qualities during the course of the class, to determine if attitudes and self-confidence levels change.

B. Methods (Describe in detail all procedures to be performed on human subjects.)
Questionnaire using Likert scale items and open-ended questions regarding skills confidence, awareness of current popular opinion and recent brain research relating to arts education, and student valuing of the arts in the curriculum. (see attached survey). Questionnaire is administered multiple times during the LS 420 to attempt to track changes in attitude and confidence level. Questionnaire is administered once after 421 in order to begin to identify the longevity of the attitude and confidence level.

III. POTENTIAL RISKS

A. Discuss the risks, if any, to the subjects.
None, as information is mostly anonymous and will be reported only with collective data, all with no identities revealed.
B. Discuss procedures for protecting against or minimizing potential risks.
Numbers used for tracking change are randomly assigned, and students are responsible for remembering their own number.
C. Are the risks reasonable in relation to the anticipated benefits, if any, to the subjects, and the importance of the knowledge that may reasonably be expected to risk confidentiality?
Information is being used to examine effectiveness of a teaching approach toward a specific objective. If shared, it will be in the context of a report on the assessment of the approach, and identities of subject remain anonymous.
D. Describe in detail all procedures to assure confidentiality of the subjects.
As long as subject remembers his/her code number to put on the questionnaire, it is totally anonymous. Names will be associated with numbers only if a student forgets his/her number and we have to compare previous questionnaires to clarify the correct number.

IV. Describe procedures for recruitment of a racially and ethnically representative population. If this will not be the case, discuss the reasons for not having such a balanced population.
The population is a cross section of the Cal Poly Liberal Studies majors (who are required to take the course in the degree plan). The research is specific to the course objectives, and thus is concerned only with students taking this course.

V. Will children be recruited for this research? If children will be recruited, justify this.
NO

VI. How will informed consent be documented?
Students currently enrolled in LS 420 will sign informed consent documents, which will be collected by the researcher, giving permission to use their data for analysis and presentation of this teaching approach. Students who have taken 421 will receive the information as part of the questionnaire and will be advised not to submit the single questionnaire if they do not consent to the use of the data.

VII. Will there be recruitment of subjects who cannot themselves provide informed consent? If so, how will informed consent be documented for this population?
NO

VIII. Does the research plan have provision for the ongoing monitoring of data collection to ensure safety of subjects? Describe the plan.
Researcher has weekly contact with students, and openly encourages students to make her aware of problems they might be having. While it is unlikely that the research questionnaires will cause any emotional or behavioral problems, researcher is alert to this type of crisis in students.

IX. Attach a copy of the Informed Consent Form to be used.