2010 Mississippi Science And Engineering Fairs Elementary Registration Form For Grades 1-6 (Page 4 of 5) in pdf

2010 MSEF School Information & SRC/IRB Committees Form

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This form MUST be completed and returned by November 30, 2009, to Your Regional Fair Director.

This form serves as an indication of your school's intent to participate in the 2010 Regional Fair.

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Section I.

Current School Information

School Name:________________________________________________________________________________________________

Mailing Address:_____________________________________________________________________________________________

School Telephone: ________________________________ School FAX: ________________________________________________

2010 Key Teacher________________________________Email_______________________________________________________

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__ Yes. Our students will be conducting experiments involving humans and/or animals. (Complete Section I and II)

__ No. Our students will not be conducting experiments involving humans and/or animals. (Complete Section I only)

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Section II. List the members of your local SRC and IRB. The SRC should have at least a biomedical scientist (PhD, M.D., D.V.M., or

D.O.), a science teacher, and one other member. The IRB should have at least a science teacher, school administrator, & either a

psychologist, psychiatrist, guidance counselor, medical doctor, or registered nurse. Members can serve on both committees. However,

teachers may NOT sign as the Chairperson.

All signatures required on Form 1B must be dated PRIOR to the beginning date of experimentation listed on Form 1A. This is

a MSEF/ISEF violation if not followed correctly.

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Local SRC Chairperson: __________________________________________________________________________________________________

Employed by: _________________________________________Employment Title: _________________________________________________

Complete Mailing Address: _______________________________________________________________________________________________

Degree(s) and/or Qualifications: ___________________________________________________________________________________________

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Local IRB Chairperson: __________________________________________________________________________________________

Employed by: __________________________________________Employment Title: ________________________________________

Complete Mailing Address: _______________________________________________________________________________________

Degree(s) and/or Qualifications: ___________________________________________________________________________________

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Other Local Committee Members. Please Check Committee. Use Additional Sheets if Necessary

Name: _________________________________________________________________________________

____SRC

___IRB

Employed by: ___________________________________________Employment Title: _______________________________________

Complete Mailing Address: _______________________________________________________________________________________

Degree(s) and /or Qualifications: ___________________________________________________________________________________

2010 Mississippi Science And Engineering Fairs Elementary Registration Form For Grades 1-6 Page 4