genIC Request Form

0920-XXXX GenIC Proposal

1. Date:

2. Name, CIO/Program:

3. Title of Study:

4. Study Type:

Cognitive Testing  Pilot Testing 

5. Purpose of Study: Discuss the purpose of the cognitive and pilot testing.

1. What do you hope to accomplish through cognitive and/or pilot testing?

2. How will the information be used?

6. Respondent Characteristics: Discuss respondent characteristics, specifically, number of subjects, age range, gender, race/ethnic composition, geographic location, and other applicable conditions.

7. Study Methods: Discuss study methods, specifically, how data will be collected (e.g., focus group, online, telephone).

8. Recruitment and Incentives: Describe the method for identifying and recruiting potential participants. If there will be an incentive, state what incentive will be offered and explain why an incentive (of this amount) is required.

9. Personally Identifiable Information (PII): If PII will be collected, describe how and what methods will be used to ensure participant privacy.

10. Informed Consent/Voluntary Participation: Detail methods for ensuring informed and voluntary participation here (e.g., steps taken to obtain informed consent, how the information will be secured).

11. Analysis of Data. Explain how data will be analyzed.

12. Collection Timeline. Describe timeline for project, listing milestones.

13. Burden Table. Please add burden table here.

Please include all data collection forms when you submit this document.