Application for an Anonymous Survey

By Federal law and guidelines and Clark University policy, all institutional and research surveys by Clark faculty, research personnel, students and staff must be reviewed and approved by the Institutional Review Board for Research Involving Human Subjects (IRB).

If the survey is not anonymous, the project must be described in the usual form, Application for Projects with Human Participants, and reviewed by the full IRB.

If the survey is anonymous, it is eligible for executive review. In this case, your application should briefly address the following issues (1-6) and include a copy of the survey (2)and Clark's ITS (Information Technology Systems x7745) software must be used so that we can assure anonymity. The ITS software is called "Checkbox®." ITS does not have the time to review all other survey programs and therefore the Clark software must be used.

This statement should be included at the end of all anonymous surveys: "This study has been approved by the Clark Committee for the Rights of Human Participants in Research and Training (IRB). Any questions about human rights issues should be directed to the IRB Chair, Dr. Linda M. Kennedy (508) 793-7476."

Provide Contact Information

Name:
Email Address:
Advisor's Name:
Dept./Campus Box:

Provide Information About Your Survey

1. Criteria for Anonymity

An anonymous survey is one in which procedures ensure that the information obtained is recorded in such a manner that the participants cannot be identified by anyone, including the surveyors, either directly or through information linked to the participants.
Do your procedures meet these criteria?

Yes
No

2. Your Procedures for Maintaining Anonymity

Describe your procedures for maintaining anonymity (e.g. paper surveys returned to a box/location not monitored by the surveyors or by mail; electronic surveys returned to a website set up so that respondents can not be traced). If you use an electronic website, include assurance from ITS or another appropriate source that the website is indeed, set up so that the participants can not be identified by you. In addition, participants should be instructed to put no identifying information about themselves on the survey itself.

3. The Nature of Your Project

Briefly describe the nature of your project and its purpose.

4. The Nature of Your Participants

Describe your participants (e.g. college students, staff, alumni, etc.).

5. How Your Participants Will Be Recruited

How will you contact the participants? Example (in person on campus, send out the survey electronically, send out a paper survey by mail)

6. Provide your recruiting text, whether written or oral.

It should include the purpose of the survey and the names and affiliations of the surveyors. It should also include statements that:

the survey is anonymous
responses cannot be traced back to participants
participation is voluntary
any question may be left unanswered
the respondent can drop out at any time

7. Risks

In your estimation, does participating in the survey involve any risk for the participants (e.g. psychological effects of the questions) and if so, address their likelihood and seriousness. Be sure to justify your answer (e.g. no risk if subject matter is not personal or political, or is innocuous).

8. The Survey Form

Forward a copy of the survey form with all the survey questions to: Gabe Johnson, RESEARCH OFFICE, RM. 209A, Geography Building (ext. 7765) It should include a statement to the participants describing

the purpose of the survey
the names and affiliations of the surveyors
the duration of time needed to complete the survey.

It should also include statements that:

the survey is anonymous
responses cannot be traced back to participants
participation is voluntary
any question may be left unanswered
the participant can drop out at any time
that respondents should not put any identifying information about themselves on the survey.

Human verification

Please use the field below to verify the letters you see in the red box: