Protocol Template for Minimal Risk Studies not Regulated by FDA

INSTRUCTIONS: You may use this document as a guide to write a protocol. You do not need to follow this document. You may use a different format, order, outline or template provided the necessary information is included. Depending on the nature of what you are doing, some sections may not be applicable to your research. If so, delete them. For simple research, such as a retrospective chart review, less than a page may be necessary to address the relevant sections. If you use this template, delete the instructions. If you already have a protocol: o Review this document to ensure that the protocol addresses the relevant information and add missing information. o If you cannot add missing information to the protocol, provide the information in a separate document. o Do not duplicate information already present in the protocol. 1) Abstract of the study Provide a summary of the study (recommended length: 250 words). 2) Protocol Title Include the full protocol title as listed on the Application for Human Research. 3) Investigator Include the principal investigator’s name as listed on the Application for Human Research. 4) Objectives Describe the study’s purpose, specific aims, or objectives. State the hypotheses to be tested. 5) Rationale and Significance Describe the relevant prior research experience and the gaps in current knowledge. Describe any relevant preliminary data. Describe how this research study will add to existing knowledge. 6) Resources and Setting Note that the City of Philadelphia’s IRB may also require approval of your study. Please contact its website for specific information: http://www.phila.gov/health/commissioner/IRB.html

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Beyond the required CITI training, describe how the investigator has ensured that all persons assisting with the study are adequately informed about the protocol and their study-related duties and functions. Describe the study facilities, including the site(s) where your research team will identify and recruit potential subjects and the site(s) where your research procedures will be performed. 7) Prior Approvals Describe any non-IRB approvals that will be obtained prior to commencing the research. (e.g., school, external site, or funding agency). 8) Study Design a) Recruitment Methods Describe how many subjects will be needed. Describe when, where, and how potential subjects will be identified and recruited. Describe materials that will be used to recruit subjects, e.g., advertisements. Describe any payments to subjects, including the amount, timing (at the end of the study or pro-rated for partial study participation), method (e.g., cash, check, gift card), and whether subjects will experience a delay in receiving the payment. b) Inclusion and Exclusion Criteria Describe the criteria that determine who will be included or excluded in the study. c) Study Timelines Describe: The duration of a subject’s participation in the study. The duration anticipated to enroll all subjects. The estimated date that the investigators will complete the study. d) Study Procedures and Data Analysis Describe the study procedures and how the data will be analyzed. e) Withdrawal of Subjects Describe any anticipated circumstances under which subjects will be withdrawn from the research without their consent.

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Describe the consequences of a subject's decision to withdraw from the research and the procedures for orderly termination of participation by the subject (e.g., the subject contacting the investigator for an end- of-study visit). f) Privacy & Confidentiality Describe whether the study will use or disclose subjects’ Protected Health Information (PHI). If the study uses or discloses PHI, the PI must do one of the following: Submit a “HIPAA Authorization English (HRP-505)” or justify a waiver of HIPAA authorization. The criteria for a waiver of HIPAA authorization can be found in the “WORKSHEET: HIPAA Waiver of Authorization (HRP-428).” Additional information regarding PHI and HIPAA can be found in the “references” section of the Temple IRB website. Describe the steps that will be taken to secure the data (e.g., training, authorization of access, password protection, encryption, physical controls, Certificates of Confidentiality, and separation of identifiers and data). Describe whether results (study results or individual subject results, such as results of genetic tests or incidental findings) will be shared with subjects or others (e.g., the subject’s professor, teacher, advisor, counselor, or primary care physician) and if so, describe how it will be shared. Describe the steps that will be taken to protect subjects’ privacy interests. “Privacy interest” refers to a person’s desire to place limits on whom they interact with or whom they provide personal information to. Describe the steps that you will take to make the subjects feel at ease with the research situation in terms of the questions being asked and the procedures being performed. “At ease” does not refer to physical discomfort, but the sense of intrusiveness a subject might experience in response to questions, examinations, and procedures. 9) Risks to Subjects List the reasonably foreseeable risks, discomforts, hazards, or inconveniences to the subjects that are related to a subject’s participation in the research. Consider the probability, magnitude, duration, and reversibility of the risks. In addition, consider physical, psychological, social, legal, and economic risks. Describe the procedures that will be taken to lessen the probability or magnitude of risks. If applicable, describe risks to others who are not subjects.

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Describe the availability of medical or psychological resources that subjects might need as a result of anticipated consequences of the research. 10) Potential Benefits to Subjects Describe the potential benefits that individual subjects (i.e., not society) may experience from taking part in the research or indicate that there is no direct benefit. 11) Costs to Subjects Describe any costs that subjects may be financially responsible for due to study participation. 12) Informed Consent Indicate whether you will follow “INVESTIGATOR GUIDANCE: Informed Consent (HRP-802).” If not, provide a description of your consent process including: o Where will the consent process take place o Any waiting period available between informing the prospective subject and obtaining the consent. o Any process to ensure ongoing consent. o The role of the individuals listed in the application as being involved in the consent process. o The time that will be devoted to the consent discussion. o Steps that will be taken to minimize the possibility of coercion or undue influence. o Steps that will be taken to ensure the subjects’ understanding. Non-English Speaking Subjects  Indicate the language(s), other than English, that are understood by prospective subjects or representatives.  If subjects who do not speak English will be enrolled, describe the process to ensure that the oral and written information provided to those subjects will be in that language. Waiver or Alteration of the Consent Process (consent will not be obtained, required information will not be disclosed, or the research involves deception)  Review the “CHECKLIST: Waiver of Consent HHS (HRP-300)” to ensure you have provided sufficient information for the IRB to make these determinations.

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 If the Human Research involves a waiver of the consent process for planned emergency research, please review the “CHECKLIST: Waiver of Consent Emergency Research (HRP-301)” to ensure you have provided sufficient information for the IRB to make this determination.  If the Human Research involves a waiver of the consent process that includes use or disclosure of protected health information (PHI), please review the “WORKSHEET: HIPAA Waiver of Authorization (HRP-428)” to ensure that you have provided sufficient information for the IRB to make these determinations. Subjects who are not yet adults (infants, children, teenagers) Describe whether parental permission will be obtained from: Both parents unless one parent is deceased, unknown, incompetent, or not reasonably available, or when only one parent has legal responsibility for the care and custody of the child. One parent even if the other parent is alive, known, competent, reasonably available, and shares legal responsibility for the care and custody of the child. Describe whether permission will be obtained from individuals other than parents, and if so, who will be allowed to provide permission. Describe the process used to determine these individuals’ authority to consent to each child’s general medical care. Indicate whether assent will be obtained from all, some, or none of the children. If assent will be obtained from some children, indicate which children will be required to assent. When assent of children is obtained, describe whether and how it will be documented. Cognitively Impaired Adults Describe the process to determine whether an individual is capable of consent. Adults Unable to Consent For research conducted in the state, indicate you will follow “POLICY: Legally Authorized Representatives Children and Guardians (HRP-021)” For research conducted out of the state list the individuals from whom permission will be obtained in order of priority. (e.g., durable power of attorney for health care, court-appointed guardian for health care decisions, spouse, and adult child.) Describe the process for assent of the subjects. Indicate whether:

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Assent will be required of all, some, or none of the subjects. If some, indicate which subjects will be required to assent and which will not. If assent will not be obtained from some or all subjects, submit an explanation. Describe whether assent of the subjects will be documented and the process to document assent. 13) Vulnerable Populations If the Human Research involves individuals who are vulnerable to coercion or undue influence, describe additional safeguards to protect their rights and welfare. Indicate whether you will include any of the following populations: Adults unable to consent Individuals who are not yet adults (infants, children, teenagers) Pregnant women Prisoners If the Human Research involves cognitively impaired adults, review the “WORKSHEET: Adults Lacking Capacity (HRP-414)” to ensure you have provided sufficient information for the IRB. If the Human Research involves persons who have not attained the legal age for consent to treatments or procedures involved in the research (“children”), review the “CHECKLIST: Children (HRP-310)” to ensure you have provided sufficient information for the IRB. If the Human Research involves pregnant women, review the “CHECKLIST: Pregnant Women (HRP-305)” to ensure you have provided sufficient information for the IRB. If the Human Research involves prisoners, review the “CHECKLIST: Prisoners (HRP-308)” to ensure you have provided sufficient information for the IRB.

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