2012 Research Plan Form 1a Template printable pdf download

RSRC approval________

2012 MASSACHUSETTS MIDDLE SCHOOL SCIENCE & ENGINEERING FAIR

RESEARCH PLAN FORM 1A

Please keep a copy of this application and any accompanying material for your records.

Student Name_______________________________________________________________Grade ________

Project Title ________________________________________________________________________________

Teacher/Adult Supervisor _____________________________________________________________________

School _________________________________________City/Town __________________________________

Teacher Phone _________________________________Teacher Active Email _________________________

Please check: ________Individual Project _______Team Project

(All forms must be completed by each member.)

PROJECT MUST NOT INVOLVE THE

ALL HUMAN RESEARCH PROJECTS MUST

FOLLOWING MATERIALS:

HAVE AN INFORMED CONSENT FORM (C)

ATTACHED

Blood products, fresh tissue, teeth and bodily fluids

Nonhuman vertebrate animals or their parts, exception is egg

All human research projects (including surveys, professional

Pathogenic agents

tests, questionnaires, and studies in which the researcher is

Recombinant DNA

the subject of his/her own research) need a Regional Safety

Controlled substances

Review Committee (RSRC) approval. Copies of

Carcinogenic, mutagenic and toxic chemicals

standardized and student prepared tests, surveys, etc. must

Explosive chemicals

be attached to the Research Plan. HUMAN CONSENT

Radioactive materials

FORM (C) must be obtained from all participants involved in

Compressed gas (including, but not limited to CO

)

human research projects. If a participant is under 18 years

Hazardous substances or devices (including, but not limited

old, the parent/guardian signature is required.

to BB guns, potato cannons, paint ball guns)

High voltage equipment

Lasers (any strength)

Ionizing radiation X-rays or nuclear energy

Check appropriate box:

I have read the above boxes, and my project does not involve any of the above materials or human

subjects.

My project involves Human Subjects and Form C is attached with all signed copies from subjects.*

My research plan needs a designated supervising adult and Form D is attached.*

(Non-pathogenic microorganisms and other safety issues. See Regulation section.)

Required Signatures

Student _____________________________________________________________________________________

Teacher _______________________________________________________________________________________

Parent/Guardian ________________________________________________________________________________

Date _________________________________________________________________________________________

Please complete forms and send to your Regional Safety Review Committee (RSRC):

Walt Horner, Regis College, Box 1010, 235 Wellesley Street, Weston, MA 02493

Deadline: April 1, 2012*

* If your project involves human subjects and/or requires a supervising adult, you must submit

forms 1A, 1B and D (if required) before experimentation begins

Forms revised 11/2/08

2012 Research Plan Form 1a Template

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