Ethical Review Form:
Human Subjects

Department of Computer Science
University of Calgary

Exact title of research:

Breif description of research goal and its methodology

• attach as separate document

Principal investigator(s)

Type of research:

• Thesis:
• • Supervisor's name:_______________________
  • ___PhD
    ___Masters
    ___Honours
    
• Class Project (research required as a course component)
  
• • Course name___________________________
    
  • Course section__________________________
    
  • Academic term__________________________
    
  • Instructor______________________________
    
• Other (explain)
  :
  :
  :

Will the project/research require ethical approval at the University level

• eg research seeking external funding from granting agencies generally requires that the University gives its ethical approval

  ____Yes____No . If yes, explain.

  :

  :

Briefly describe the sample of persons to be used in this study

• eg ages, gender, special status...
  
  :

  :

Method of recruiting subjects

• :

  :

Estimate the amount of time you will require of each subject in the study/project, including frequency of tests

• eg 3 sessions, once per week for 3 weeks, for a total of 3 hours
  :

  :

Do you intend to pay or renumerate subjects for their participation?

• ____Yes____No . If yes, how?

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Will you be using any form of deception?

• Yes____ No____. If yes, explain.

  :

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Will this study involve any of the following manipulations?

• ___Physiological

  ___Emotional

  ___Upsetting situations (e.g., upsetting questions on a questionairre)

  ___Any other controversial or potentially risky manipulations

  If yes to any of the above, explain.

  :

  :
  

Is there any risk to subjects (physical and/or psychological)? Y

• Yes___ No___.
  If yes, please explain fully what the risks are, how you plan to mitgate these, and justify their necessity.
  :

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How do you plan to handle the requirements of confidentiality?

• (eg subject identity, release of raw data, videotapes of subjects to be shown at conferences, etc)?
  
  :

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How do you plan to debrief subjects after the experimental situation?

• :

  :
  

Will informed consent be obtained?

• Yes___ No___.

• If no, please explain fully in a separate attachment why no informed consent will be obtained.
  If yes, attach a copy of the informed consent agreement. Also indicate:

  From whom will informed consent be obtained?_____________________________________________

  :

  Will they receive a clear explanation, in a language they can understand, of the nature and purpose(s) of this study? ____Yes___No
  If no, explain.

  :

  Will they be informed of what will be required of them?____Yes____No.
  If no, explain.

  :

  Will they be told the amount of time expected of them?____Yes____No.
  If no, explain.

  :

  Will they be informed of the risks, if any? ____Yes____No.
  If no, explain

  :

  Will they be given the opportuntiy to ask questions during and after their involvement? ____Yes____No.
  If no, explain.\

  :

  Will they be informed that their participation is voluntary?____Yes____No
  If no, explain.

  :
  
  If yes, will they be:

  • given the opportunity to refuse?____Yes____No. If no, explain.
    :
    :
  • told they have the right to refuse to answer any question?____Yes____No. If no, explain.
    :
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  • told that they are free to withdraw at any time without penalty?____Yes____No. If no, explain.
    :
    :

The principal investigator agrees that changes to any or all of the stated information on this form, subsequent to ethical approval, will require another ethical review.

Name of principal investigator:_________________________________ Position:_______________________________

Signature:_________________________________________________Date:__________________________________

This is to certify that the Department of Computer Science Ethics Review Committee (Human Subjects) has examined and approved the ethics of the attached research/thesis project.

Chair:_______________________________

Member:_____________________________

Member:_____________________________