GUIDE TO COMPLETING THE PINE RIDGE PROJECT REQUEST FORM

The Pine Ridge Project Request Form (PRR) for is the form used to record and review requests to complete a student project at the Pine Ridge Family Health Center (PRFHC). The PRR form required for all projects requesting access to the Pine Ridge community. This form serves as formal notice to the Advisory Council and the Topeka Housing Authority leadership of the intent to conduct a research project at the Pine Ridge Family Health Center. In addition, the form will allow the Advisory Council to track all requests and provide the means for facilitating the project. The properly completed form must be submitted to the Advisory Council when the student starts initial work on the project, or at least 30 days before the proposed project start, whichever is earlier. Each student participating in the project should complete and submit a request form. If approved, students are required to present project activities and findings to the PRFHC Advisory Council at the first quarterly meeting following the project end date.

This guide should be used to assist faculty and students to properly complete the PRR form. Please be sure to complete all information requested, including a brief description of the project and submit the form to the PRFHC Advisory Council Chair. For additional assistance regarding the process, please contact Mari Tucker at 785-670-1224 or mari.tucker@washburn.edu. Copies of this form can be downloaded from the Topeka Housing Authority webpage.

 

INTENT TO SUBMIT A STUDENT PROJECT REQUEST FORM

Section 1.

• Student Name: Full name of the student participating in the project.
• WIN and Email: Enter the student WIN number(s) (or other institution ID number) and email address(es).
• Faculty: Faculty member managing and evaluating the student project.
• Faculty Contact: Faculty email address and phone number.
• Washburn School/Program: Please indicate the major academic unit(s) or other entity for the faculty and student. Students from other institutions should provide full detail in the “Other” category.
• Project Detail: Description of the proposed project and details on resident interaction. • Proposed Project Start Date: Enter the starting date for the project.
• Proposed Project End Date: Enter the end date for the project.
• IRB Approval: Indicate if IRB approval has been secured and, if so, the date of the approval.
• C2C Modules Completed by all Students: Students are required to complete the D2L Classroom to Community modules of “Trauma-Informed Care” and “Social Justice”. Indicate the date of completion.
• Faculty Signature: Signature of supervising faculty.
• Student Signature: Signature of requesting student.

Section 2.

AREA RESERVED FOR THE PINE RIDGE ADVISORY COUNCIL

This section will be completed by the PRFHC Advisory Council Chair after the PRR form has been reviewed. The Chair will document the request and forward the form and supporting documents to the PRFHC Advisory Council for review and approval.

Faculty and students will be advised of the Advisory Council decision within 14 working days of the submitted request.