A-5 Permission Plan

Learner’s Name: Click or tap here to enter text.

Research Method and Design: Click or tap here to enter text.

Mentor’s Name:Click or tap here to enter text.

Plan instructions: Students must complete all sections of this plan. If a section is not applicable to the proposed study provide a statement explain why. Only after mentor approval of this document is obtain may the student seek to obtain the permissions needed.

Section 1: Instruments proposed for use

Students must obtain written permission to use existing instruments for data collection. This permission must be made from the instrument author or publisher or their recognized representatives. Failure to obtain permission to use an instrument represents unauthorized use and is a copyright violation.

List each instrument separately

Provide the name and contact information for the holder of any rights to the use or distribution of the instrument

Provide, specifically, the means you will use to obtain instrument permission; attach a copy of any correspondence you intend to use.

If this section is not applicable to your proposed study, please provide a brief explanation of why

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Seciton 2: Site Permission

Students must obtain written site permission for research activities, including but not limited to data collection or participant contact, when the proposed research focuses on or will be conducted at an organization or institution. Site permission graded by an organization or institution must be signed by an appropriate or designated representative of the organization or institution, dated within six months of submission of the proposal to the IRB, and written on the organization or institution’s official letterhead.

· List each permission separately

· Provide the name and contact information for the individual capable of providing site permission as the appropriate and designated representative of the organization or institution.

· Provide, specifically, the means you will use to obtain site permission; attach a copy of any correspondence you intend to use

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Seciton 3: Draft of Informed consent (does not need to be completed by participants at until irb approval)

Students must obtain written informed consent from human participants involved in the research study. Participants must voluntarily agree to provide data or to take part in the research activities after reviewing clear and accurate information concerning the research study. The informed consent form is a written document that conveys information about the purpose of the study and the role the participant will play in completing the research. Participants must sign the form after an opportunity to review and ask questions about the research study. Students must provide a copy of the signed informed consent form to the participant if requested to do so.

· Provide a statement of what informed consent is needed to complete the research study

· Attached a copy of the proposed informed consent document, which will be provided to participants

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Seciton 4: Conflict of Interest Plan

Students encounter a conflict of interest in research when competing interest exists that may potentially impact a researcher’s decisions, judgment, objectivity or other interests. Such conflicts frequently arise when a researcher conducts a study in his or her place of employment or with his or her professional/personal clients, employees, or contacts. Whenever practical, students should eliminate completely any conflict of interest or appearance of conflict. This is done effectively by conducting research at a site where the student does not have an affiliation or association. If this is not possible, the student must:

· Provide a statement disclosing all conflict of interest exists, and

· Provide a detailed and specific plan for how the research may be conducted to reduce or manage the identified conflict.

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Student’s Signature

Mentor Approval

Approved ☐

Not Approved ☐