Title: Institutional Review Board (IRB) Application for Quality Improvement or Innovation Project Approval
Herzing University’s Institutional Review Board (IRB) reviews all student quality 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 quality improvement processes. After submitting the application, the IRB will notify the applicant, in writing, of its decision or if additional information 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 DNP 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 Quality Improvement or Innovation Project Approval
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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: __________________________________
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| Email: | |
| Primary Phone Number: |
Step 2: Location, Faculty, and Date Information
| Location/Sponsor: | |
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Faculty Information: |
Faculty Name: |
| Faculty Email: | |
| Faculty Phone: | |
| Anticipated Start Date: | |
| Anticipated Completion
Date: |
Step 3: Aim Statement Overview
| Aim Statement
Key elements of the aim statement needed to be included: 1. What? What’s the problem or opportunity? 2. How much? By how much will you improve? Or “how good” do you want to get? 3. By when? What is the date by which you will achieve the level of improvement you’ve set out to accomplish? 4. For whom? Who is the customer or population who will benefit from the improvement? 5. Where? What are the boundaries of the process or system you’re trying to improve? Where does it begin and end?
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| Project Overview
Please provide a summary of the proposed quality 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.
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| QI Framework
Please provide an overview of the framework that will be utilized in the proposed project (e.g. KTA, PDSA, ADKAR, Lean, Six Sigma, DMAIC, etc.).
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| 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.
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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 research project.