Ethics Statement
(Submitted for Approval
to Conduct Research
in the School of Business and Management, ITB)
Name of Student:
Student Registration number:
Phone and e-mail address:
Course Number and Title for which the research is being conducted:
Name of course convenor (telephone and e-mail details):
Title of Research:
Brief description (150 words) of Research
Dates of Research (from - to):
Sites(s) where research will be conducted:
Ethics Code(s) consulted in preparation for this application for approval:
Items within the code which are especially relevant to this research:
Is the Description of Research Particulars being submitted with this form? If not why?
Declaration by the Investigator/s:
I/We have considered the ethical implications of the proposed research and have
consulted relevant ethical codes of practice, and accept responsibility for the conduct
of the research detailed in this application accordingthe practice described in
acknowledged codes of practice as detailed in the proposal.
Name: Date
:
(Signature of Principal Investigator)
I have read the statement concerning the ethical implications of the proposed
research and confirm that it complies with the regulations regarding the course and
that appropriate consideration has been given to ethical issues which may arise in the
research.
Name: Date
:
(Signature of course convenor)
Declaration by the Head of School (or delegate (head of Committee for Teaching
and Learning or Head of Research Committee or Head of S1 Study
programme):
The project set out in the attached application, including the adequacy of its research
design and compliance with recognised ethical standards, has the approval of the
School. I certify that I am prepared to have this project undertaken in my
School/Centre/Unit.
Name:
Date:
(Signature of Head of School or approved delegate)
School/Centre:
Extn:
Description of Research Particulars
(To include information on the headings below to be submitted with the application
for approval)
Section A: Details of participants
1. Number, type, age range, any special characteristics of participants
2. Source of participants (attach written permission where appropriate)
3. Means by which participants are to be recruited
4. Are any of the participants "vulnerable" or in a dependent relationship with
any of the investigators, particularly those involved in recruiting for or
conducting the project?
Section B: Risk classification and estimation of potential risk to participants
1. Please identify the risk classification for your project by assessing the level of
risk to participants or (if any) to the researcher on a scale of 1 -5 (1=minimal
risk, 5= very high risk).
2. If you believe the project should be classified level 2 or level 1 please explain
why you believe there are minimal risks to the participants.
OR
If you believe the project is classified level 3 please identify all potential risks
to participants associated with the proposed research. Please explain how you
intend to protect participants against or minimise these risks.
3. Please explain how the potential benefits to the participant or contributions to
the general body of knowledge outweigh the risks.
4. Contingency planning: first aid /steps taken to avoid health and saftey risks to
researcher/ debriefing
5 Adverse Events: Are procedures in place to manage, monitor and report
adverse and/or unforeseen events that may be associated with your research,
for example names of contact persons in case of emergency? Give details:
6. Please complete this checklist by placing Y (Yes) or N (No) and give details
of any other ethical issues that may be associated with this project.
Ye
s
No
a Is deception to be used?
b Does the data collection process involve access to personal or sensitive
data without the prior consent of participants?
c Will participants have pictures taken of them eg, photographs, video
recording, radiography?
d Will participants come into contact with any equipment which uses an
electrical supply in any form eg, audiometer, biofeedback, electrical
stimulation, etc?
e If interviews are to be conducted will they be tape-recorded?
f Do you plan to use an interpreter?
g Will participants be asked to commit any acts which might diminish
self-esteem or cause them to experience embarrassment or regret?
h Does the research involve any stimuli, tasks, investigations or
procedures which may be experienced by participants as stressful,
noxious, aversive or unpleasant during or after the research procedures?
i Are the participants in any sort of dependent relationship with the
investigator/s?
j Are participants asked to disclose information that may leave them
feeling vulnerable or embarrassed?
k Are there in your opinion any other ethical issues involved in the
research?
Where you have answered Yes to any of the questions on the checklist, please give
details and state what action you intend to take to ensure that no difficulties arise for
your participants.
For all items details must be included in the explanatory statement
Section C: Informed consent
1. Attach to the application your explanatory statement & consent form ie the
form you will be asking informants to sign. Please note that the following
should be considered in the consent form.
Does the explanatory statement cover the following:
The identity of the organisation collecting the information and how
to contact it?
Yes No
The purposes for which the information is being collected? Yes No
The period for which the records relating to the participant will be
kept?
Yes No
The steps taken to ensure confidentiality and secure storage of data?
Yes No
How privacy will be protected and confidentiality be ensured in any
publication of the information?
Yes No
The fact that the individual may access that information? Yes No
Any law that requires the particular information to be
collected/disclosed? (eg notifiable diseases or mandatory reporting
obligations re child abuse)
Yes No
Not Applicable
The consequences (if any) for the individual if all or part of the
information is not provided? (eg any additional risks if a participant
does not fully disclose his/her medical history)
Yes No
Not Applicable
If you answered No to any of these questions, give the reasons why this information
has not been included in the explanatory statement.
2. Dissemination of results (Say how results will be disseminated)
Section D: Collection of Information
(a) Does the project involve collection of information directly from individuals
about themselves?
No (If collected from a third party/existing records) You must fill
out the Special Privacy Form (Form 5) as well as this form.
Yes answer the following questions:
(b) What type of information will be collected? (Tick as many as apply)
personal information
sensitive information
health information
Is there any further information regarding ethical issues which those who are signing
the approval form need to be aware of?
