Trees

Institutional Review Board

Sample Form: Permission To Conduct Study

NOTE: NOT ON NDNU LETTERHEAD

Date
Mr. X
Head of School or Center
Address

RE: Permission to Conduct Research Study

Dear Mr. X:

I am writing to request permission to conduct a research study at your institution or (e.g., after school center).  I am currently enrolled in the (specify program) at Notre Dame de Namur University in Belmont, CA, and am in the process of writing my (i.e., Master’s Thesis).  The study is entitled (specify).

I hope that the school administration will allow me to recruit (i.e., specify x number of individuals, boys, girls; indicate age of children) from the school to anonymously complete a 4-page questionnaire (copy enclosed).  Due to the nature of the study, I hope to recruit (the mother, father, or guardian) of these students to anonymously complete their own 2-page questionnaire (copy enclosed).  Interested students, who volunteer to participate, will be given a consent form to be signed by their parent or guardian (copy enclosed) and returned to the primary researcher at the beginning of the survey process.  Parents who volunteer to participate will also be given consent forms to be signed and returned to the primary researcher (copy enclosed).

If approval is granted, student participants will complete the survey in a classroom or other quiet setting on the school site. (Indicate when and where i.e., recess, during school time, lunch, after school and ask permission for use of this time as well).  The survey process should take no longer than (specify time commitment).  Parent participants would complete the survey at home.  The survey results will be pooled for the thesis project and individual results of this study will remain absolutely confidential and anonymous.  Should this study be published, only pooled results will be documented.  No costs will be incurred by either your school/center or the individual participants.

Your approval to conduct this study will be greatly appreciated.  I will follow up with a telephone call next week and would be happy to answer any questions or concerns that you may have at that time. You may contact me at my email address:_________________________________.

If you agree, kindly sign below and return the signed form in the enclosed self-addressed envelope.  Alternatively, kindly submit a signed letter of permission on your institution’s letterhead acknowledging your consent and permission for me to conduct this survey/study at your institution.

Sincerely,

Researcher name and affiliation

Enclosures

cc:        Dr. Z, Research Advisor, NDNU

Approved by:

_____________________         ____________________       _________

Print your name and title here     Signature                               Date