Form 1 - Checklist for Adult Sponsor/Safety Assessment

Please complete all required sections. After you click Save and Submit, you will have a chance to review the form. At this point, please print the form out before you finalize it and have your legal guardian sign it.

THIS FORM AND A ONE PAGE TYPED RESEARCH PLAN ARE DUE JANUARY 16th, 2009.

Last Name *

First Name *

Science Instructor *

Science Class Section *

*
I have reviewed and approved the research plan for this project

Does this project involve any of the following which require additional approval from the instructor and Department Chair: *
Human Subjects
Non-human Vertebrae Animals
Pathogenic Agents
Controlled Substances
Recombinant DNA
Human or Non-human invertebrate animal tissue
Doesn't involve any of the above

Does this project involve any of the hazardous substances or devices listed below which require additional approval by the instructor, Department Chair and supervision by a qualified scientist: *
Explosive, hazardous, highly toxic, carcinogenic, or mutagenic materials (e.g. pesticides)
Welders, lasers or voltage greater than 220 volts
Firearms
Radioactive substances
Radiation
Doesn't involve any of the above

____________________________ ________________________ ____________

Legal Guardian's Printed Name Signature Date

Captcha

Please enter the characters you see in this picture:

Characters

This helps prevent automated form submissions. If you are not sure what the characters are, make your best guess. You will have another try in the next screen.
Can't see the image? Click here for an audible version in English.

Need assistance with this form?