Fort Worth Regional Science And Engineering Fair Checklist Form Page 2

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Form 2: Qualified Scientist Form
[ ]
Item 1
Student Name and Project Title ________________________________________________________
[ ]
Item 2
Qualified Scientist’s Information (8 Blanks) _____________________________________________
[ ]
Item 3
Questions 1- 4 _____________________________________________________________________
[ ]
Item 4
Scientist Name, Signature Date Before Experiment ______________________________________
[ ]
Item 5
If applicable: Name, Sigature Date Before Experiment ____________________________________
Form 3: Risk Assessment
[ ]
Item 1
Student Name and Project Title ________________________________________________________
[ ]
Item 2
Questions 1-5 ______________________________________________________________________
[ ]
Item 3
Name, Signature, etc., Date Before Experiment __________________________________________
Form 4: Human Subjects Form
[ ]
Item 1
Student Name and Project Title ________________________________________________________
[ ]
Item 2
Question 1-3 ______________________________________________________________________
[ ]
Item 3
Adult sponsor, and E-mail ____________________________________________________________
[ ]
Item 4
IRB Risk Box _____________________________________________________________________
[ ]
Item 5
Medical Prof. Signature and Approval date ______________________________________________
[ ]
Item 6
Science Teacher Signature and Approval date
_____________________________________________
[ ]
Item 7
School Administrator Sig & Approval Date ______________________________________________
[ ]
Item 8
Human Subject Boxes, Signed & dated _________________________________________________
[ ]
Item 9
Parent Consent boxes, signed & dated __________________________________________________
Form 5A: Vertebrate Animal (SRC Approval)
[ ]
Item 1
Student Name and Project Title ________________________________________________________
[ ]
Item 2
Questions 1-3 (Completed by Student Researcher) _________________________________________
[ ]
Item 3
SRC Boxes before Experiment _______________________________________________________
[ ]
Item 4
Vet/Designated Supervisor Info (if applicable) ____________________________________________
Form 5B: Vertebrate Animal (IACUC Approval)
[ ]
Item 1
Student Name, Project Title, and Protocol Number ________________________________________
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Item 2
Questions 1-6 (Completed by Qualified Scientist) _________________________________________
[ ]
Item 3
Question 7: ensure copy of approval letter attached
__________________________________________
[ ]
Item 4
Certification Box with Sig, Date, etc. ___________________________________________________
Form 6A: Potentially Hazardous Biological Agents
[ ]
Item 1
Student Name and Project Title ________________________________________________________
[ ]
Item 2
Questions 1-5 (Completed by Student Researcher) _________________________________________
[ ]
Item 3
Second part completed by QS or DS ____________________________________________________
[ ]
Item 4
BSL-1 Lab or BSL-2 Lab Signature, and Date ____________________________________________
Form 6B: Human and Vertebrate Animal Tissue
[ ]
Item 1
Student Name and Project Title ________________________________________________________
[ ]
Item 2
Questions 1-3 (Completed by Student Researcher) _________________________________________
[ ]
Item 3
Certification Box Completed by DS or QS with date _______________________________________
Form 7: Continuation Projects
[ ]
Item 1
Student Name ____________________________________________________________________
[ ]
Item 2
Components Completed by Student Researcher ___________________________________________
[ ]
Item 3
Student Name, Signature, and Date _____________________________________________________

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