TOPAZ ACCOUNT REQUEST
Principal Investigatior Information
Name
*
First Name
Last Name
TSU Email
*
Best Contact Number
*
Best Contact Number Type
*
Cell
Home
Work
Other
Alternate Contact Number
*
Alternate Contact Number Type
*
Cell
Home
Work
Other
Subject/Participant Type
*
Animal
Human
College or School
*
Business
Communications
Education
Graduate School
Health Sciences
Law
Liberal Arts & Behavioral Sciences
Office of Information and Technology
Pharmacy
Public Affairs
Science & Technology
Department
*
Accounting and Finance
Business Administration
Department
*
Communication Arts & Sciences
Entertainment and Recording Industry
Radio, Television, and Film
Department
*
Continuing Education
Counselor Education
Curriculum and Instruction
Educational Administration & Foundations
Health and Kinesiology
Department
*
Clinical Laboratory Science
Environmental Health
Health Administration
Health Care Administration
Health Information Management
Respiratory Therapy
Department
*
English
Fine Arts
Foreign Languages
History, Geography and Economics
Human Services and Consumer Sciences
Psychology
Social Work
Sociology
Department
*
Pharmaceutical Sciences
Pharmacy Practice
Department
*
Administration of Justice (AJ)
Political Science (POLS)
Public Administration
Urban Planning and Environmental Policy
Department
*
Biology
Chemistry
Computer Science
Engineering Technologies
Environmental Toxicology
Industrial Technologies
Mathematics
Physics
Transportation Studies
I am a TSU
*
Student
Faculty
Protocol Reviewer Information
This section is required to be completed by all TSU principal investigators.
Faculty Reviewer Name
First
Last
Faculty Reviewer Role (e.g., Advisor, Committee Chair, Committee Member, etc.)
Faculty Reviewer TSU Email
Faculty Reviewer Contact Phone
CITI Program Membership
Are you a member of the CITI Program Online Training?
*
Yes
No
Confidentiality Agreement
*
I acknowledge and agree that I shall keep secret all confidential and proprietary information and not reveal or disclose it to anyone unless required by my supervisor or a University official to do so. I agree that if I commit a breach of this agreement, the University shall have the right to take disciplinary action against me and to otherwise enforce this agreement.
Yes
Applicant Signature
*
Press and hold the left mouse button in the box and draw your signature.
If you want to delete it and try again simply press "Clear" icon in the bottom right corner.
Date
*
Date Format: MM slash DD slash YYYY