UCI Human Subjects Pool Application 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] Yes If yes, please reserve space with front desk in SSL 488. No 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:__________________________________ E-mail:_________________________________ Name(s): _______________________________ Phone Number:__________________________________ E-mail:_________________________________ 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: ________________ □ □ 199 299 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.