$ confirm that $ have read the current version of the University of Sheffield %Ethics /olicy Governing Research $nvolving 1uman /articipants /ersonal 2ata and 1uman 0issue& as sho!n on the University&s research ethics !e3site at' !!!#sheffield#ac#uk+ris+other+gov,ethics+ethicspolicy A1. Title of research project:
A2.
Email/
Tel#/
A4#
End date/
A5#
Mark %6& in one or more of the follo!ing 3o(es if your research' involves adults with mental incapacity or mental illness involves prisoners or others in custodial care 0e#g# young offenders1 involves children or young people aged under 3: years involves using samples of human biological material collected before for another purpose involves taking new samples of human biological material 0e#g# blood& tissue1 7 involves testing a medicinal product ; involves taking new samples of human biological material 0e#g# blood& tissue1 7 involves additional radiation above that re uired for clinical care 7 involves investigating a medical device 7
; )f you have marked bo<es marked 7 then you also need to obtain confirmation that
appropriate University insurance is in place# To do this email insurance=shef#ac#uk and re uest a copy of the 'Clinical Trial )nsurance !pplication -orm(#
)t is recommended that you familiarise yourself with the University(s Ethics "olicy >overning Research )nvolving ?uman "articipants& "ersonal 9ata and ?uman Tissue before completing the following uestions# "lease note that if you provide sufficient information about the research 0what you intend to do& how it will be carried out and how you intend to minimise any
risks1& this will help the ethics reviewers to make an informed judgement uickly without having to ask for further details#
A8# i#
9riefly summarise' 0he pro"ect&s aims and o3"ectives' 0this must be in language comprehensible to a lay person1
ii#
A:#
;hat is the potential for physical and+or psychological harm + distress to participants<
A=#
2oes your research raise any issues of personal safety for you or other researchers involved in the pro"ect< 0especially if taking place outside working hours or off University premises1
A>#
$f yes e(plain ho! these issues !ill 3e managed# 1o! !ill the potential participants in the pro"ect 3e' i# $dentified<
ii#
Approached<
iii#
Recruited<
A?#
;ill informed consent 3e o3tained from the participants< $E% $f informed consent or consent is *O0 to 3e o3tained please e(plain !hy# -urther guidance is at/ www#sheffield#ac#uk*ris*other*gov8 ethics*ethicspolicy*policy8notes*consent @ A
A?#)# This uestion is only applicable if you are planning to obtain informed consent/ 1o! do you plan to o3tain informed consent< @i#e# the proposed process<A' A)B# ;hat measures !ill 3e put in place to ensure confidentiality of personal data !here appropriate<
A))#
;ill financial + in kind payments @other than reasona3le e(penses and compensation for timeA 3e offered to participants< 0)ndicate how much and on what basis this has been decided1
A)-#
;ill the research involve the production of recorded media such as audio and+or video recordings< $E% @ A
A)-#)# This uestion is only applicable if you are planning to produce recorded media/ 1o! !ill you ensure that there is a clear agreement !ith participants as to ho! these recorded media may 3e stored used and @if appropriateA destroyed<
>uidance on a range of ethical issues& including safety and well8being& consent and anonymity& confidentiality and data protection( are available at/ www#sheffield#ac#uk*ris*other*gov8ethics*ethicspolicy*policy8notes
Student 2eclaration
@0he student completes Anne( ) if the Supervisor has classed the student&s proposed research pro"ect as %lo! risk&A
0he Supervisor needs to receive an electronic copy of the form and other documents !here appropriate plus a signed dated paper copy of this Anne( ) %the Student 2eclaration&# -ull Research "roject Title/
insert here
The research ethics application form for the above8named project is accurate to the best of my knowledge and belief# The above8named project will abide by the University(s '>ood Research "ractice %tandards(/ www#sheffield#ac#uk*ris*other*gov8ethics*good The above8named project will abide by the University(s 'Ethics "olicy >overning Research )nvolving ?uman "articipants& "ersonal 9ata and ?uman Tissue(/ www#sheffield#ac#uk*ris*other*gov8ethics*ethicspolicy %ubject to the above8named project being ethically approved ) undertake to adhere to any ethics conditions that may be set# ) will inform my %upervisor of significant changes to the above8named project that have ethical conse uences# ) will inform my %upervisor if prospective participants make a complaint about the above8named project# ) understand that personal data about me as a researcher on the research ethics application form will be held by those involved in the ethics review process 0e#g# my %upervisor and the Ethics !dministrator1 and that this will be managed according to 9ata "rotection !ct principles# $ understand that this pro"ect cannot 3e su3mitted for ethics approval in more than one department and that if $ !ish to appeal against the decision made this must 3e done through the original department#
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Supervisor 2eclaration
@0he Supervisor completes Anne( - if s+he has classed the student&s proposed research pro"ect as potentially %high risk&A
0he Ethics Administrator needs to receive an electronic copy of the form and other documents !here appropriate plus a signed dated paper copy of this Anne( - %the Supervisor 2eclaration&#
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insert name
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