Vice Presidency for Planning and Academic Affairs s1

Sistema Universitario Ana G. Méndez Vice Presidency for Planning and Academic Affairs Associate Vice Presidency for Sponsored Programs Office for Regulatory Compliance

INSTRUCTIONS

Exempt Review Process

The Exempt Form IRB-F08 will be used to submit a study/research that may be considered for exempt review. Download and refer to the Exempt Checklist Sheet for other documents that should be submitted with this application. All studies must comply with categories as defined in the Federal Regulations governing research involving human subjects. These categories include the following:

 Study of normal educational practices in commonly accepted educational settings  Survey/interview/educational testing of adult subjects (anonymous data collection or non-sensitive topic areas)  Survey/interview/educational testing of public officials  Public observation of adults and children (if researchers do not interact with the children)  Use of existing data or specimens if researchers do not record identifiable information  Taste and food quality evaluation and consumer acceptance studies

For more details, Part VIII of the IRB_F08 Form should be completed.

Research involving prisoners do not qualify for exempt status. Research involving other vulnerable subject populations may not qualify as exempt. Please contact your Institutional Compliance Coordinator, contact information is available in our IRB web page http://compliance.suagm.edu or discuss the specifics of your study/research if you are not sure whether your study qualifies for an exempt status.

Approval of exempt study/research will be determined by SUAGM’s IRB. As per Federal guidance, determinations of exemption are not to be made by the investigator. All study/research approved exempt will submit changes (amendments), continuing review, closures, and others to SUAGM’s IRB.

All submission forms and templates are available under “Formularios” which can be found in our IRB webpage http://compliance.suagm.edu. After downloading and completing necessary forms they should be saved in a computer under a file identified as study documents. Investigators are advised not to save current forms for future use because IRB forms are updated on a regular basis. Forms that are not currently published on line at the moment of submission will be not be accepted. Page 2 of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) SISTEMA UNIVERSITARIO ANA G. MÉNDEZ Vice Presidency for Planning and Academic Affairs Associate Vice presidency for Sponsored Programs Office of Regulatory Compliance

Human Research Protection Board (IRB) EXEMPT STUDY/RESEARCH SUBMISSION FORM This form and all other required documents must be submitted through the IRBNet platform. It is important that all instructions are read. Please refer to http://compliance.suagm.edu Instructions Before starting to fill out this form it is important that you review all parts to make sure you have all the required documents for submission. This form should be completed in order to request IRB review for research involving human subjects. Incomplete or unreadable applications will not be accepted for IRB review. Download this form, complete and upload again in the IRBNet System with all other documents required. The 45 CFR 46 “Common Rule” prohibits that any research (including recruitment of subjects or advertising) be initialized without IRB review and approval. All researchers (i.e. Primary Investigators, Faculty, Mentor, Students and all key personnel) must receive educational training on Human Subjects Research in order to receive exemption or approval of their protocols from the IRB. All researchers and key personnel involved in investigations must complete the online training module on Human Subjects Protection (IRB), Privacy and Confidentiality and RCR Certificate (as required) at http://www.citiprogram.org ) include copy of certifications with this submission). Please refer to “Instructions for On-line Certification” which you can find in our webpage (compliance.suagm.edu). You should also upload the obtained certifications in IRBNet System with other required documents.

IT IS HIGHLY RECOMMENDED TO REFER TO AND COMPLETE PART VIII OF THIS FORM IN ORDER TO CERTIFY THAT THE STUDY/RESEARCH QUALIFIES FOR EXEMPT REVIEW. ONCE THIS IS CONFIRMED COMPLETE ALL OTHER PARTS OF THIS FORM AND SUBMIT WITH REQUIRED DOCUMENTS FOR IRB APPROVAL

I. PRINCIPAL INVESTIGATOR/STUDENT INFORMATION Last First/Initial Highest Earned Degree 1. Name

2. Mailing Address

3. Institution/ University Campus School/Department/ Program

4. E-mail Address

Phone Fax 5. Phone/Fax

Undergraduate Graduate Student Staff Faculty Visiting Faculty Other 6. Category

of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) II. MENTOR PERSONAL INFORMATION: The Mentor must have completed all required certifications mentioned in the instructions above. Certifications will be verified by the Institutional Compliance Coordinator before IRB review is granted. Last First/Initial Highest Earned Degree 1. Name

2. Mailing Address

4. E-mail Address

Staff Faculty Visiting Faculty Other 6. Category Specify

III. CO-PI PERSONAL INFORMATION: Co-Investigators must have completed all required certifications mentioned in the instructions above. Certifications will be verified by the Institutional Compliance Coordinator before approval before IRB review is granted. Last First/Initial Highest Earned Degree 1. Name

2. Mailing Address

4. E-mail Address

Staff Faculty Visiting Faculty Other 6. Category Specify

Describe the role that will be carried out by the Co-PI in the research indicating all activities. Team members may be grouped into categories. 7. Co-PI’s Role

NOTE: If the study has more than one CO-PI, please attach the information at the end of this document following this same format.

IV. ADDITIONAL TEAM MEMBERS PERSONAL INFORMATION:

of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) It is the PI’s responsibility to train additional team members in the required certifications mentioned in the instructions above. If required, official documentation of these trainings must be presented to the Institutional Compliance Coordinator. Last First/Initial Highest Earned Degree 1. Name

2. Mailing Address

4. E-mail Address

Staff Faculty Visiting Faculty Other 6. Category Specify Describe the role that will be carried out by this member in the research indicating all activities. Team members may be grouped into categories. 7. Research Team Role

8. Email If you would like one or two of your team members (in addition to the Co PI/Mentor) to be Communications: copied on all email communications, please list these individuals in the box below. Name: E-mail:

Name: E-mail:

NOTE: If the study has more than one Additional Team Member, please attach the information at the end of this document following this same format.

V. BASIC STUDY INFORMATION If you already have developmental approval for this research study, please give the IRB 1.Developmental Approval protocol number assigned to the study. More information available here.

2. Study/ResearchTitle

3. If different, title used on consent document(s)

4. If class project, include course number and title

of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) 5. Estimated Project Estimated start date (may not be prior to IRB approval, consider ten (10) working days after Duration, after IRB application submitted date). approval Starting Date: / / Completion Date: / / MO DAY YR MO DAY YR

Anticipated completion date (please include time needed for analysis of individually identifiable data):

6. Study Purpose In non-technical terms, provide a brief description of the purpose of the study. Upon conclusion of the study, how will you share your results (e.g., academic publication, evaluation report to funder, conference presentation)?

Description:

VI. FUNDING SOURCE: Please select all that apply

Submitted for internal funding Internally funded Submitted for external funding Funding source: if applicable (Do not use initials): Proposal number (PPN) for the Office of Sponsored Programs: Name of PI on Funding Proposal:

Externally funded Funding source, if applicable (Do not use initials): Proposal number (PPN) for the Office of Sponsored Programs: Name of PI on Funding Proposal:

Intend to seek funding. From whom? Not funded

VII. Other IRB Approvals:

1. Has this research study been presented to any other IRB? Yes No

2. Where? When?

3. If yes, what was their decision? Approved Not Approved Pending

4. Please attach a copy of any submissions, approvals, or Non approvals from other IRB’s.

VIII. Exempt Review Checklist: To determine whether this study meets the federal requirements for exemption [45 CFR 46.101], please complete the following checklist. This will indicate if your study can be reviewed under the exemption category. The Federal Code [45 CFR 46.101] permits research activities in the following six categories to be exempted. Please check the relevant exemption category / categories. 1. Research conducted in established or commonly accepted educational settings, involving normal educational practices, such as:

of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) a. research on regular and special education instructional strategies , OR b. research on the effectiveness of or the comparison among instructional techniques, curricula, or classroom management methods.

NOTE: Survey and interview procedures with minors are exemptible if the activities fall within this category.

2. Research involving the use of educational test (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures or observation of public behavior, UNLESS: a. the information obtained is recorded in such a manner that human participants can be identified, directly or through identifiers linked to the participants; AND b. any disclosure of the human participants responses outside the research could reasonably place the participants at risk of criminal or civil liability or be damaging to the participants financial standing, employability, or reputation.

NOTE: Survey and interview techniques which include minors are not exempt. Observation of the public behavior of minors, if the researcher is not a participant, is exempt.

3. Research involving the use of educational tests (cognitive, diagnostic, aptitude, achievement), survey procedures, interview procedures, or observation of public behavior that is not exempt under Category 2, if: a. the human participants are elected or appointed public officials or candidates for public office, or b. federal statute(s) require(s) without exception that the confidentiality of the personally identifiable information will be maintained throughout the research and thereafter.

4. Research, involving the collection or study of existing data, documents, records, pathological specimens, or diagnostic specimens, if these sources are publicly available or if the information is recorded by the investigator in such a manner that participants cannot be identified directly or through identifiers linked to the participants. Note: If you select this category please be aware that after completing this section you must refer to Part VIII.A.

5. NOTE: Please contact the Office of Regulatory Compliance selecting this category since use of this exemption must be initiated by the agency head of the federal funder.

Research and demonstration projects which projects which are conducted by or subject to the approval of appropriate Federal Department or Agency heads, and which are designed to study, evaluate, or otherwise examine: a. public benefit or service programs; or b. procedures for obtaining benefits or services under those programs; or c. possible changes in or alternatives to those programs or procedure; or d. Possible changes in methods or levels of payment for benefits or services under those programs.

6. Taste and food quality evaluation and consumer acceptance studies, a. if wholesome foods without additives are consumed, OR b. if a food is consumed that contains a food ingredient at or below the level and for a use found to be safe, or agricultural chemical or environmental contaminant at or below the level found to be safe, by the Food and Drug Administration or approved by the Environmental Protection Agency or the Food Safety and Inspection Service of the U.S. Department of Agriculture.

VIII.A. If you selected Exemption Category B4, please complete the following questions:

1. What are the types of data or specimens?

2. What is the source of the data or specimens?

3. Are the data or specimens publicly available? (That is, can the general public obtain the data or specimens? Data are

of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) not considered publicly available if access is limited to researchers.) Yes No If yes, please contact the Institutional Compliance Coordinator for consultation. You may not be conducting research involving human subjects as defined in the federal regulations governing research involving human subjects (45 CFR 46.102).

4. If the data or specimens are not publicly available, how are you obtaining permission to access these or to use them for research purposes? Please attach a copy of the correspondence or agreement granting you permission.

5. How will the data be made available to you (e.g., electronic file, access to hard copy records at record-holder’s institution)?

6. How are the data or specimens identified when they are made available to you?

a. Direct Identifier (e.g., subject name, address, or social security number). b. Indirect Identifier (e.g., an assigned code that could be used by the investigator or the source providing the data or specimens to identify a subject, such as a pathology tracking number or a tracking code used by the source). If you will receive data with indirect identifiers only, please contact the Institutional Compliance Coordinator for consultation. You may not be conducting research involving human subjects as defined in the federal regulations governing researching research involving human subject (45 CFR 46.102).

c. Not Identifier (i.e., neither the researcher not the source providing the data or specimens can identify a subject based upon information provided with the data or specimens).

If it will be impossible for anyone to identify subjects based upon information provided with the data or specimens, you will not be conducting research involving human subjects as defined in the federal regulations governing research involving human subjects (45 CFR 46). Please contact the Institutional Compliance Coordinator for confirmation. 7. If (a) is checked above, will you record any direct identifiers that are available to you?

* Yes No

8. Will any data or specimens be collected from participants after the submission of this application? (Data or specimens are considered to “exist” if ALL the data or specimens to be used for the research have been collected prior to the submission of this application.)

* Yes No

If your answer YES to this question your research does not qualify for exemption from IRB review under Exemption Category 4. PLEASE NOTE: If you are applying for exemption only under Exemption Category 4, you have now completed this application.

IX. STUDY SAMPLE: (Groups specifically targeted for study)

Describe the participants you plan to recruit and the criteria used in the selection process. Indicate inclusion or exclusion criteria.

Describe:

NOTE: If individuals who are incarcerated will be participants, your research does not qualify for exempt review. Please

of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) complete the F01 Application Form. (It may be required to complete other documents)

Age range of participants: Projected number of participants:

0 – 6 (submit consent of parent or legally authorized Minimum of participant(s): representative) 7- 13 (submit consent of parent or legally authorized representative and child assent will be Maximum of participant(s): required from 7-13 years of age) 14-20 (submit a consent for participant and parent or legally authorized representative, if applicable) 21 – 65

66 years or more Select Study Population: (all that apply)

Employees Students Pregnant women * Minors (under 21)* Fetuses /neonates * Educationally / economically disadvantaged* Minors who are wards of the state, or any Individuals who are incarcerated* (does not qualify for other agency, institution, or entity * exempt review) Non-Spanish Speaking* Military personnel Persons incompetent to give valid consent* Other-specify: * State necessity for using this type of participant:

X. STUDY LOCATION: (Select all that apply) A. SUAGM Location SUAGM SISTEMA TV AGM VIRTUAL Universidad Metropolitana, Cupey PR Universidad del Este, Carolina, PR Universidad del Turabo, Gurabo, PR Aguadilla Cabo Rojo Yabucoa Jayuya Santa Isabel Cayey Bayamón Barceloneta Barceloneta Comerío Yauco Ponce Metro Orlando (MOC) Arecibo Isabela South Florida (SFC) Metro Orlando (MOC) Metro Orlando (MOC) Tampa Bay (TBC) South Florida (SFC) South Florida (SFC) Maryland (CAC) Tampa Bay (TBC) Tampa Bay (TBC) Dallas (DAC) Maryland (CAC) Maryland (CAC) Other (Specify) Dallas (DAC) Dallas (DAC) Other (Specify) Other (Specify)

B. External Location School System / Individual Schools Other University / College Other – specify

You need to obtain permission if participants will be recruited or data will be obtained through schools, employers, or community organizations. Are you required to obtain permission to gain access to people or to access data that are not publicly available? If yes, provide a research site letter from a person authorized to give you access to the participants or to the data.

of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) Research Site Letter(s) not required. Research Site Letter(s) attached. Error: Reference source not found Research Site Letter(s) pending and will be provided when obtained.

Internet Research – The use of internet does not exclude the PI from complying with Federal Law and Regulations, all of the following process should be described as indicated. (Other documents may be required).

XI. RECRUIT METHOD

Describe how research participants will be recruited for the study. How will you identify potential participants? How will you contact them? Attach a copy of any material you will use to recruit participants (e.g., advertisements, flyers, telephone scripts, verbal recruitment, cover letters, or follow-up reminders). The process previously solicited must be described even if your recruitment will be done by internet and all materials and/or link should also be included.

Describe:

XII. PARTICIPANT INCENTIVE

1. Will you pay participants? Yes No

Amount: $ When will money be paid?

2. Will you give participants incentives / gifts / reimbursements? Yes No

Describe incentives / gifts / reimbursements: Value of incentives / gifts / reimbursements: $ When will incentives / gifts / reimbursements be given?

3. Will participants receive course credit? Yes No

4. Will participants receive extra credit? Yes No

If yes, an equivalent alternative to research participation must be provided and described in your informed consent document(s).

XIII. INFORMED CONSENT 1. Attach a copy of the informational letter or consent script you plan to provide to your participants (and their parents or guardians, if applicable). You can access Consent Document Templates in our webpage http://compliance.suagm.edu. Indicate how this process will be managed even if the study will be done by internet.

XIV. PROCEDURE

1. What data will you collect?

2. Please describe in detail the process each participant will experience and how you will obtain the data.

3. How many participation sessions and how much time will be required for each participant, including follow up sessions?

of 11 SUAGM_IRB_Exempt_F08 Eng_Ver (Rev 07/2016) 4. How will you collect data?

in-person contact telephone USPS mail emails (include templates) website (include link) other, specify written document

Please include copies of surveys, interview questions, data collection tools and debriefing statements. If survey or interview questions have not fully developed, provide information on the types of questions to be asked, or a description of the parameters of the survey / interview. Please note: finalized survey or interview instruments will need to be reviewed and approved by amendment, before implementation, this includes Internet Research.

a. Will you audio record participants? Yes No b. Will you video record participants? Yes No c. Will you photograph participants? Yes No

5. Protection of Confidentiality: Describe the security measures you will take to protect the confidentiality of the information obtained. Will participants be identifiable either by name or through demographic data? If yes, how will you protect the identity of the participants and their responses? Where will the data be stored and how will it be secured? Who will have access to the data? How will identifiers be maintained or destroyed after the study is completed? This process should also be described even if the data will be obtained by internet.

Describe:

6. Conflict of Interest Statement: Could the results of the study provide an actual or potential financial gain to you, a member of your family, or any of the co-investigators, or give the appearance of a potential conflict of interest? No Yes, I agree to disclose any actual or potential conflict of interest prior to IRB action on this study.

XVI. PI/ MENTOR/DEAN Signature (signature is obtained electronically under the IRBNet Platform) I have reviewed this research protocol and the informed consent document(s), if applicable. I submit this study for approval to AGMUS’ IRB. I understand that, I have ultimate responsibility for the protection of the rights and welfare of human subjects, conduct of the study and the ethical performance of the project. I further certify that the proposed research is not currently being conducted and will not begin until SUAGM IRB approval has been obtained.

For further information please contact your Institutional Compliance Coordinator

UMET (787) 766-1717 ext. 6366 - E-mail: [email protected] UNE (787) 257-7373 ext. 2279 - E-mail: [email protected] UT (787)743-7979 ext. 4126 - E-mail: [email protected]; Fax: (787) 743-7115 EE.UU. SUAGM University System (813) 932-7500 ext. 8711 - Email : [email protected] Adm. Central (787) 751-0178 ext. 7195 – E-mail : [email protected]

To report an adverse event E-mail: [email protected] (787) 751-0178 ext 7195 and 7197 or non compliance in Research: E-mail [email protected] (787) 751-3120

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