Bev app revision

Herzing University’s Institutional Review Board (IRB) reviews all student improvement or innovation project protocol requests to determine if it is human subject research that meets definitions in The Common Rule and therefore requires review and oversight by the IRB. It is the investigator’s responsibility to give complete information regarding the planned improvement processes. After submitting the IRB application, the student will be notified in writing of IRB completed review signaling ability for the project to commence or if additional information and review relative to human subject protection is needed.

Checklist

Please make sure to submit the following items along with this application for your submission:

· This application with signatures from you and your Project Faculty

· A copy of all questionnaires and surveys, if used

· A copy of your CITI Certification (free certification for Herzing affiliates through Canvas)

· A copy of the application and approval letter from any external IRB ( if applicable)

· Letter of approval from the Program Chair of the affiliated institution ( if applicable)

Institutional Review Board (IRB) Application for Improvement or Innovation Project Approval

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Institutional Review Board (IRB) Application for an Improvement Process or Innovation Project Approval

Step 1: Your Information

Project Title:
Doctorate Student Name:
Check One:	· Herzing University Student · Student not affiliated with Herzing University – list institution this project is affiliated with: __________________________________
Email:
Primary Phone Number:

Step 2: Location, Faculty, and Date Information

Location/Sponsor:
Faculty Information:	Faculty Name:
	Faculty Email:
	Faculty Phone:
Anticipated Start Date:
Anticipated Completion Date:

Step 3: Aim Statement Overview

Aim Statement Construct a succinct Aim Statement for the proposed project that also includes a brief description of the selected intervention/innovation. Utilize guidance provided by the Institute for Healthcare Improvement worksheet as an aid to guide your construction. https://www.ihi.org/sites/default/files/2023-11/IHITool_Aim-Statement-Worksheet.pdf

Project Overview Please provide a summary of the proposed improvement or innovation project including the purpose, proposed strategy to be utilized, proposed project measures that will be utilized to evaluate outcomes, and the anticipated/desired outcomes.

Improvement Framework Please provide an overview of the improvement framework that will be utilized in the proposed project (e.g. KTA, PDSA, ADKAR, Lean, Six Sigma, DMAIC, etc.).

Data Security Please provide a description of your data security plan for both physical and electronic data that includes protected or identifying personal information. Include where the data will be stored, the security of the location or computer system, the length of retention of the data, and the method of disposition of old data.

Step 4: Acknowledgement of Responsibilities and Signatures

Please note that:

· Any data collected from Herzing University students, alumni, faculty and/or staff and/or any other constituents for purposes of this project is proprietary. Any publication of findings may not identify or implicate Herzing University. Any external report produced on findings generated by this study, including any presentation or publication, may not identify, reference or implicate Herzing University in any way.

· Upon completion of the project, a copy of the final deliverable will be submitted to Herzing University.

· Any additional publications or presentations produced based upon this project will be submitted to Herzing University.

I certify to the best of my knowledge the information presented is an accurate reflection of the proposed improvement project.

Doctorate Student Signature: Date:

Project Faculty Signature: Date:

Program Chair Signature: Date:

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