RESEARCH APPLICATION CHECKLIST Incomplete …ccsd.net/resources/aarsi-research/pdf/research/...A...

Application Number __________ Date Application Received ___________

November 2010 CCSD Research Department, AARSI Division

RESEARCH APPLICATION CHECKLIST Please use this list to verify that you completed all required steps in preparing your CCSD Research

Application. Incomplete applications will not be accepted and will be returned to the applicant. Application submitted at least 60 days in advance of research commencement *

The Applicant/Principal Investigator is:

• Student – when master’s or doctoral and first-hand involvement • Faculty – when academic research first-hand involvement

CCSD Research Application: Parts A, B, C fully completed *

Human Subjects Protection Training Certificate of Completion *

CCSD Letter of Acknowledgement – School access investigated *

Institutional Review Board Approval Letter *

Consents/Assents with University IRB with stamped approval indicia *

Instruments (surveys, interview protocol and/or text, observation protocol)

Signature(s): Part D

• Applicant * • Faculty Advisor, if applicable *

Sponsor, if applicable: Part E (The sponsor must be a principal, director or above.)

For additional details and information, please contact:

Cheryl King, Administrative Clerk Research Department Clark County School District 4260 Eucalyptus Avenue, Annex C Las Vegas, Nevada 89121-5207 (702) 855-7783 ext. 5270 Alternate: (702) 799-5195 Fax: (702) 799-0292

* Required with CCSD Research Application



RESEARCH APPLICATION PART A: APPLICANT INFORMATION & PROJECT IDENTIFICATION 1.0 Project Title:

2.0 Duration of Project Anticipated Start Date: Anticipated End Date:

3.0 Applicant Contact Information Name and Credentials (First, Middle, Last): Mailing Address ( If you are a CCSD employee please provide an address other than your work location):

Street Address City, State, Zip

E-Mail Address: Telephone Number:

Are you employed by the Clark County School District? □ Yes □ No If yes, please complete the following: Position Title: Work Location Name: Work Location Number:

4.0 Research is to be conducted as: Part of work duties (CCSD employees only) An individual only A faculty member of an institution of higher education A researcher contracted by CCSD to perform the research A vendor of products A student seeking: □ Bachelors □ Masters □ Doctorate Other (Please identify the organization): Extension of currently approved CCSD research project



5.0 If your research is to be conducted as a student seeking a degree, please complete Sections 5.1 and 5.2 below.

5.1 Research advisor/director information Name (First, Middle, Last): Degree: Current Institution Mailing Address:

Street Address City, State, Zip

E-Mail Address: Telephone Number:

5.2 Research/research design courses completed by applicant (list by title) 1. 2. 3. 4.

6.0 Research Team Members List all research team members (including principal investigator) who will have contact with subjects, have contact with subjects’ data, or use subjects’ personal information. NOTE: All research team members must submit a Human Subjects Protection Training Certificate (i.e. CITI Certificate, NIH Certificate, or other).

Name (First, Middle, Last) Role in Protocol

7.0 Sponsorship Information

Is your project sponsored by a CCSD Principal, Department Director or higher? □ Yes □ No If yes: Name of sponsor (First, Middle, Last): Position Title: Department/Division:



8.0 Funding source for this research: 9.0 Compensation for Research Subjects Will you give subjects gifts, compensation, reimbursement, or services without charge or incentives? □ Yes □ No

If yes, please explain in detail. NOTE: Compensation for research subjects will be reviewed to ensure compliance with CCSD policies and regulation



PART B: DESCRIPTION OF THE STUDY 10.0 Define the problem to be investigated in this proposed study. Include relevant background

information. 11.0 List the question(s) to be answered or the hypothesis(es) to be tested by the research. 12.0 Describe the research design and methods to be used in the research. Design/methods examples: descriptive, formative, phenomenological, ethnographic, qualitative,

quantitative, oral history, fieldwork, mixed methods, experimental, quasi-experimental, etc. If a mixed-methods study, provide design/methodology information for each component of the project.



13.0 Describe the sampling plan exactly as it will occur. Include information about the recruitment/selection of subjects. NOTE: Copies of all

recruitment/selection materials must be attached to this application (e.g. advertisements, notices, e-mails, letters, and phone scripts).

14.0 Describe the data collection methods in detail. Be sure to address securing permission and making arrangements with principals or department

heads who are responsible for the potential subjects of the study. Describe where, how long, and in what format data will be kept. Also indicate what security provisions will be taken to protect the data and ensure confidentiality. NOTE: Copies of surveys, interview questions, focus group questions, and other data collection instruments must be attached to this application.



15.0 Describe the data analysis in detail. Include statistical analyses that will be conducted if using quantitative data. If using qualitative data

describe how the data will be organized, coded and described. 16.0 Summarize the data collection methods. Select all that apply.

Researcher Obtained

Academic tests Observation Student records Psychological intervention/treatment records Medical records Subject Self-Report

Survey/questionnaire Interview Observation Personal interaction with subjects

17.0 List the sources of data that ARE dependent on school/district records. Be specific (e.g., academic grades, attendance). 18.0 Indicate the office/school level(s) targeted by the research.

District Office Area Alternative School

Exceptional Students School Elementary School Middle School

High School



19.0 List the site(s) where the research will take place. A letter of acknowledgement from each site administrator must be submitted with this application. 20.0 Indicate the number of participants and/or subjects in the research. Use the total column if the grade designation is not applicable. Participants Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12 Total Students Teachers Principals Parents Others 21.0 Estimate the amount of time the research project will require of each type of participant. List the time units in decimal parts of an hour using chart below. (e.g., 1.5 hours).

Participants Testing/ Assessment Interview Observation Training Other Total

Students Teachers Principals Parents Other

Minutes 0-2 3-8 9-14 15-20 21-26 27-32 33-38 39-44 45-50 51-56 57-59 Hours 0 .1 .2 .3 .4 .5 .6 .7 .8 .9 1.0



22.0 Explain the expected value of research to education in general. 23.0 Explain the expected value of research to CCSD in particular



PART C: PROTOCOL FOR RESEARCH INVOLVING HUMAN SUBJECTS 24.0 SUBJECTS: Indicate efforts that will be made to assure equitable (gender, ethnicity etc. as

appropriate) selection. When vulnerable populations are involved, describe why they are necessary.

Minimal Risk Moderate Risk High Risk

25.0 RISKS: Describe any potential risks to the subjects – physical, psychological, social, or legal – and

assess the likelihood and seriousness of those risks. If the methods of research create potential risks, describe other methods that were considered and why they will not be used. Describe procedures, including confidentiality standards, for minimizing potential risks.

26.0 BENEFITS: Describe the anticipated benefits of the research to the individual subjects, to the

particular group or class from which the subject population is drawn, and/or to society in general.



27.0 RISK-BENEFIT RATIO: Assess the relative weights of the study's risks and benefits. 28.0 COSTS TO SUBJECTS: If the investigation involves the possibility of added expense in time or in

money to the subject or to a third party, indicate how this is justified. Be sure this is mentioned in the consent form.



PART C: PROTOCOL FOR RESEARCH INVOLVING HUMAN SUBJECTS 29.0 INFORMED CONSENT: Describe the method of collecting informed consent and who will be

responsible for obtaining same. When drafting the informed consent form(s), be sure to include all elements (risks, confidentiality, and debriefing). The approved consent form(s) must be included with the seal of approval provided to you by your institutional review board.

30.0 CHILD/YOUTH ASSENT: When children are subjects for research, assent from child (Child/Youth

Assent Form) and permission from parent (Informed Consent Form) must be obtained. These are two separate documents.

Yes, Attached Not Applicable 31.0 DESCRIBE DATA STORAGE: It is the responsibility of the researcher to retain records

relating to the research for at least three years after completion of the project. Include who is responsible for storing data, where the data will be stored, how long the data will remain in storage, and who will destroy the data and how.



PART D: APPLICANT SIGNATURES Please obtain all appropriate signatures below.

Applicant (Print):

Applicant (Signature): Date:

Faculty Advisor (Print):

Faculty Advisor (Signature): Date:

Instructions for submission of this page: 1. Print this page 2. Obtain Signatures 3. Send original signed page to CCSD Research Department



PART E: CCSD SPONSOR SIGNATURES: Sponsored research is research that is considered desirable or of special interest to a CCSD division, department, or school. If you are officially sponsoring a research application, your responsibility would be to review the application "to ensure that (1) the proposed research serves an educational purpose and (2) the benefits of conducting the research justify the costs." You would also be responsible for monitoring the project as it is conducted at any CCSD site, but not to the extent of acting as advisor to the project or applicant. Please consider the following questions as you review this application. Record your judgments in the appropriate box beside the question. If a criterion is not met, please indicate what will be necessary for the criterion to be met in the space provided.

Question Meets Criterion

Does Not Meet Criterion

Comment, if no

1. Is this project relevant to the mission of the CCSD?

2. Is the intrusiveness of the research outweighed by its potential benefit to the District?

3. Are the research activities compatible with the public school setting?

CCSD Sponsor (Print): CCSD Sponsor (Signature): Date:

(The sponsor must be a principal, director or above.)

Instructions for submission of this page: 1. Print this page 2. Obtain Signatures 3. Send original signed page to CCSD Research Department

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