UCI Human Subjects Pool Application Fall 2014 – Summer 2015

UCI Human Subjects Pool
Fall 2014 – Summer 2015
IRB HS #: ______________________
IRB expiration date: _____________________________
Researcher name: __________________________________________________________________________
[Once the application has been approved, this person will be e-mailed a login & password for the SONA experiment scheduling
system at uci.sona-systems.com]
Phone number:_____________________________________ E-mail: ________________________________
Faculty Sponsor Name: __________________________________ E-mail:_____________________________
Location of Study: _________________________
Need to Reserve space in the HSLab?
[List all rooms to be used. If an online study, indicate here]
If yes, please reserve space with front desk in SSL 488.
Selection Criteria:__________________________________________________________________________
[i.e. Left-handed only. Note: if none, then write N/A]
Participation Credit:_______________
[List ½ credit for ½ hr, 1 credit for 1 hr, etc.]
Research Assistant:
Name(s): _______________________________ Phone Number:__________________________________
Name(s): _______________________________ Phone Number:__________________________________
Title of Experiment:________________________________________________________________________
Description of Experiment:
[Maximum 250-characters, concrete description of each task involved.]
Type of research (please check):
Faculty Research
Dissertation 290
H111A student
Number of Subjects needed this year:___________
Faculty Sponsor’s signature*
112A student
Other, please specify:
Hours of timeslots needed:___________
[max .400 hours per quarter]
Experimenter’s signature*
*I am aware that violation of any subject pool regulation will result in the loss of approval for its use and blockage from accessing the online experiment system.