Checklist for Adult Sponsor (1)

This completed form is required for ALL projects.

To be completed by the Adult Sponsor in collaboration with the student researcher(s):

Student’s Name(s): Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Project Title:
1. o I have reviewed the Intel ISEF Rules and Guidelines.
2. o I have reviewed the student’s completed Student Checklist (1A) and Research Plan.
3. o I have worked with the student and we have discussed the possible risks involved in the project.
4. o The project involves one or more of the following and requires prior approval by an SRC, IRB, IACUC or IBC:
o Humans Potentially Hazardous Biological Agents
o Vertebrate Animals o Microorganisms o rDNA o Tissues

5. o Items to be completed for ALL PROJECTS

o Adult Sponsor Checklist (1) o Research Plan
o Student Checklist (1A) o Approval Form (1B)
o Regulated Research Institutional/Industrial Setting Form (1C) (when applicable after completed experiment)
o Continuation/Research Progression Form (7) (when applicable)
6. Additional forms required if the project includes the use of one or more of the following (check all that apply):
o Humans (Requires prior approval by an Institutional Review Board (IRB); see full text of the rules.)
o Human Participants Form (4) or appropriate Institutional IRB documentation
o Sample of Informed Consent Form (when applicable and/or required by the IRB)
o Qualified Scientist Form (2) (when applicable and/or required by the IRB)
o Vertebrate Animals (Requires prior approval, see full text of the rules.)
o Vertebrate Animal Form (5A)—for projects conducted in a school/home/field research site (SRC prior approval
required.)
o Vertebrate Animal Form (5B)—for projects conducted at a Regulated Research Institution. (Institutional Animal
Care and Use Committee (IACUC) approval required prior experimentation.)
o Qualified Scientist Form (2) (Required for all vertebrate animal projects at a regulated research site or when
applicable)
o Potentially Hazardous Biological Agents (Requires prior approval by SRC, IACUC or Institutional Biosafety
Committee (IBC), see full text of the rules.)
o Potentially Hazardous Biological Agents Risk Assessment Form (6A)
o Human and Vertebrate Animal Tissue Form (6B)—to be completed in addition to Form 6A when project
involves the use of fresh or frozen tissue, primary cell cultures, blood, blood products and body fluids.
o Qualified Scientist Form (2) (when applicable)
o Hazardous Chemicals, Activities and Devices (No prior approval required, see full text of the rules.)
o Risk Assessment Form (3)
o Qualified Scientist Form (2) (required for projects involving DEA-controlled substances or when applicable)

Note: The following are exempt from prior review but require a risk assessment: projects involving protists, archae
and similar microorganisms, for projects using manure for composting, fuel production or other non-culturing
experiments, for projects using color change coliform water test kits, microbial fuel cells, and for projects involving
decomposing vertebrate organisms.

Adult Sponsor’s Printed Name Signature Date of Review

Phone Email

Page 28 International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef
 Student Checklist (1A)
This form is required for ALL projects.

1. a. Student/Team Leader: Grade:

Email: Phone:

b. Team Member: c. Team Member: ______________________________

2. Title of Project:
Uretricity system: an energy converting device using subtrate compound found in urine

3. School: School Phone:

School Address:

4.
Adult Sponsor: Phone/Email:

5. Does this project need pre-approval? o Yes o No Tentative start date: ____________

6. Is this a continuation/progression from a previous year? o Yes o No

If Yes:
a. Attach the previous year’s o Abstract and o Research Plan
b. Explain how this project is new and different from previous years on o Continuation/Research Progression
Form (7)

7. This year’s laboratory experiment/data collection:

Actual Start Date: (mm/dd/yy) End Date: (mm/dd/yy)

8. Where will you conduct your experimentation? (check all that apply)
o
Research Institution o School o Field o Home o Other: ________________________

9. List name and address of all non-school work site(s):

Name:
Address:

Phone:

10. Complete a Research Plan/Project Summary following the Research Plan instructions and attach to this
form.

11. An abstract is required for all projects after experimentation.

International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef Page 29
 Research Plan and Post Project Summary Instructions
A complete Research Plan and Post Project Summary is required for ALL projects and
must accompany Student Checklist (1A).

1. The Research Plan is a succinct detailing of the rationale, research question(s), methodology, and risk assessment of your research
project and should be completed before experimentation. For all projects requiring preapproval, this document must be reviewed and
approved by the appropriate approval committee (e.g. IRB, IACUC, SRC) before experimentation. ALL changes made to the original plan
should be added to the final document as part of the Post Project Summary. For projects not requiring preapproval, this document may
be completed either pre- or post-experimentation.
2. All projects should complete a Post Project Summary after experimentation.

The Research Plan and Post Project Summary should include the following::
a. What is the RATIONALE for your project? Include a brief synopsis of the background that supports your research problem and
explain why this research is important scientifically and if applicable, explain any societal impact of your research.
b. State your HYPOTHESIS(ES), RESEARCH QUESTION(S), ENGINEERING GOAL(S), EXPECTED OUTCOMES. How is this based on the
rationale described above?
c. Describe the following in detail:
• Procedures: Detail all procedures and experimental design including methods for data collection. Describe only your project. Do
not include work done by mentor or others.
• Risk and Safety: Identify any potential risks and safety precautions needed.
• Data Analysis: Describe the procedures you will use to analyze the data/results that answer research questions or hypotheses.
• Discussion of Results and Conclusions: Discuss the data/results and the conclusions that can be drawn.
d. Bibliography: List at least five (5) major references (e.g. science journal articles, books, internet sites) from your literature review. If
you plan to use vertebrate animals, one of these references must be an animal care reference.

Items 1–4 below are subject-specific guidelines for additional items to be included in your research plan/project summary as
applicable.
1. Human participants research:
• Participants. Describe who will participate in your study (age range, gender, racial/ethnic composition). Identify any vulnerable
populations (minors, pregnant women, prisoners, mentally disabled or economically disadvantaged).
• Recruitment. Where will you find your participants? How will they be invited to participate?
• Methods. What will participants be asked to do? Will you use any surveys, questionnaires or tests? What is the frequency and
length of time involved for each subject?
• Risk Assessment
◊◊ Risks. What are the risks or potential discomforts (physical, psychological, time involved, social, legal, etc.) to participants? How
will you minimize the risks?
◊◊ Benefits. List any benefits to society or each participant.
• Protection of Privacy. Will any identifiable information (e.g., names, telephone numbers, birth dates, email addresses) be
collected? Will data be confidential or anonymous? If anonymous, describe how the data will be collected anonymously. If not
anonymous, what procedures are in place for safeguarding confidentiality? Where will the data be stored? Who will have access to
the data? What will you do with the data at the end of the study?
• Informed Consent Process. Describe how you will inform participants about the purpose of the study, what they will be asked to
do, that their participation is voluntary and they have the right to stop at any time.
2. Vertebrate animal research:
• Briefly discuss potential ALTERNATIVES to vertebrate animal use and present a detailed justification for use of vertebrate animals
• Explain potential impact or contribution this research may have
• Detail all procedures to be used
◊◊ Include methods used to minimize potential discomfort, distress, pain and injury to the animals during the course of
experimentation
◊◊ Detailed chemical concentrations and drug dosages
• Detail animal numbers, species, strain, sex, age, source, etc.
◊◊ Include justification of the numbers planned for the research
• Describe housing and oversight of daily care
• Discuss disposition of the animals at the termination of the study
3. Potentially hazardous biological agents research:
• Describe Biosafety Level Assessment process and resultant BSL determination
• Give source of agent, source of specific cell line, etc.
• Detail safety precautions
• Discuss methods of disposal
4. Hazardous chemicals, activities & devices:
• Describe Risk Assessment process and results
• Detail chemical concentrations and drug dosages
• Describe safety precautions and procedures to minimize risk
• Discuss methods of disposal

Page 30 International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef
 Approval Form (1B)
A completed form is required for each student, including all team members.

1. To Be Completed by Student and Parent

a. Student Acknowledgment:
• I understand the risks and possible dangers to me of the proposed research plan.
• I have read the Intel ISEF Rules and Guidelines and will adhere to all International Rules when conducting
this research.
• I have read and will abide by the following Ethics statement
Scientific fraud and misconduct are not condoned at any level of research or competition. Such practices include
plagiarism, forgery, use or presentation of other researcher’s work as one’s own, and fabrication of data. Fraudulent
projects will fail to qualify for competition in affiliated fairs and the Intel ISEF.

Student’s Printed Name Signature Date Acknowledged (mm/dd/yy)

(Must be prior to experimentation.)
b. Parent/Guardian Approval: I have read and understand the risks and possible dangers involved in the Research
Plan. I consent to my child participating in this research.

Parent/Guardian’s Printed Name Signature Date Acknowledged (mm/dd/yy)

(Must be prior to experimentation.)

2. To be completed by the local or affiliated Fair SRC

(Required for projects requiring prior SRC/IRB APPROVAL. Sign 2a or 2b as appropriate.)

a. Required for projects that need prior SRC/IRB b. Required for research conducted at all Regulated
approval BEFORE experimentation (humans, Research Institutions with no prior fair SRC/IRB
vertebrates or potentially hazardous biological OR approval.
agents).
This project was conducted at a regulated research
The SRC/IRB has carefully studied this project’s Research institution (not home or high school, etc.), was
Plan and all the required forms are included. My reviewed and approved by the proper institutional
signature indicates approval of the Research Plan before board before experimentation and complies with the
the student begins experimentation. Intel ISEF Rules. Attach (1C) and required institutional
approvals (e.g. IACUC, IRB).

SRC/IRB Chair’s Printed Name

SRC Chair’s Printed Name

Signature Date of Approval (mm/dd/yy)

(Must be prior to experimentation.) Signature Date of Approval (mm/dd/yy)

3. Final Intel ISEF Affiliated Fair SRC Approval (Required for ALL Projects)

SRC Approval After Experimentation and Before Competition at Regional/State/National Fair

I certify that this project adheres to the approved Research Plan and complies with all Intel ISEF Rules.

Regional SRC Chair’s Printed Name Signature Date of Approval

State/National SRC Chair’s Printed Name Signature Date of Approval

(where applicable)

International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef Page 31
 Regulated Research Institutional/Industrial Setting Form (1C)
This form must be completed AFTER experimentation by the adult supervising the student research conducted
in a regulated research institution, industrial setting or any work site other than home, school or field.
This form MUST be displayed with your project; responses must be on the form.

Student’s Name(s) Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Title of Project Uretricity system: an energy converting device using subtrate compound found in urine

To be completed by the Supervising Adult in the Setting (NOT the Student(s)) after experimentation:
(Responses must remain on the form as it is required to be displayed at student’s project booth.)

The student(s) conducted research at my work site:

a. o to use the equipment b. o to perform experiment(s)/conduct research
1. Have you reviewed the Intel ISEF rules relevant to this project? o Yes o No

2. Is this research a subset of your work? o Yes o No

3. How did the student get the idea for her/his project?
(e.g. Was the project assigned, picked from a list, an original student idea, etc.)

4. Did the student(s) work on the project as a part of a research group? o Yes o No
If yes, how large was the group and what kind of research group was it (students, group of adult researchers, etc.)

5. What specific procedures or equipment did the student(s) actually use for the project?
Please list and describe. (Do not list procedures student only observed.)

6. How independent or creative was the student’s/students’ work?

Student research projects dealing with human participants, vertebrate animals or potentially hazardous biological
agents require review and approval by an institutional regulatory board (IRB/IACUC/IBC). Copy of approval(s) must
be attached, if applicable.

Supervising Adult’s Printed Name Signature Title

Institution Date Signed (must be after experimentation)

Address Email/Phone

Page 32 International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef
 Qualified Scientist Form (2)
May be required for research involving human participants, vertebrate animals, potentially hazardous biological agents, and
DEA-controlled substances. Must be completed and signed before the start of student experimentation.
Student’s Name(s) Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Title of Project Uretricity system: an energy converting device using subtrate compound found in urine

To be completed by the Qualified Scientist:

Scientist Name:
Educational Background: Degree(s):
Experience/Training as relates to the student’s area of research:

Position: Institution:

Address: Email/Phone:
1) Have you reviewed the Intel ISEF rules relevant to this project? o Yes o No

2. Will any of the following be used?

a. Human participants o Yes o No
b. Vertebrate animals o Yes o No
c. Potentially hazardous biological agents (microorganisms, rDNA and tissues,
including blood and blood products) o Yes o No
d. DEA-controlled substances o Yes o No

3. Was this study a sub-set of a larger study? o Yes o No

4. Will you directly supervise the student? o Yes o No
a. If no, who will directly supervise and serve as the Designated Supervisor?
b. Experience/Training of the Designated Supervisor:

To be completed by the Qualified Scientist: To be completed by the Designated Supervisor

when the Qualified Scientist cannot directly supervise.
I certify that I have reviewed and approved the Research
Plan prior to the start of the experimentation. If the student I certify that I have reviewed the Research Plan and have been
or Designated Supervisor is not trained in the necessary trained in the techniques to be used by this student, and I will
procedures, I will ensure her/his training. I will provide advice and provide direct supervision.
supervision during the research. I have a working knowledge of
the techniques to be used by the student in the Research Plan.
I understand that a Designated Supervisor is required when
the student is not conducting experimentation under my direct Designated Supervisor’s Printed Name
supervision.

Signature Date of Approval

Qualified Scientist’s Printed Name

Signature Date of Approval Phone Email

International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef Page 33
 Risk Assessment Form (3)
Required for projects using hazardous chemicals, activities or devices and microorganisms exempt from
pre-approval. Must be completed before experimentation.

Student’s Name(s) Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Title of Project Uretricity system: an energy converting device using subtrate compound found in urine

To be completed by the Student Researcher(s) in collaboration with Designated Supervisor/Qualified

Scientist: (All questions must be answered; additional page(s) may be attached.)

1. Identify and assess the risks involved in this project.

The Usage of acids specifically citric acids may cause serious eye irritation if it came into contact with
your eyes.

2. Describe the safety precautions and procedures that will be used to reduce the risks.
We will be wearing safety gloves and

3. List all hazardous chemicals, activities, or devices that will be used; identify microorganisms exempt from
pre-approval (see Potentially Hazardous Biological Agent rules).

4. Describe the disposal procedures that will be used (when applicable).

5. List the source(s) of safety information.

To be completed and signed by the Designated Supervisor (or Qualified Scientist, when applicable):
I agree with the risk assessment and safety precautions and procedures described above. I certify that I have reviewed the
Research Plan and will provide direct supervision.

Designated Supervisor’s Printed Name Signature Date of Review (mm/dd/yy)

Position & Institution Phone or email contact information

Experience/Training as relates to the student’s area of research

Page 34 International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef
 Human Participants Form (4)
Required for all research involving human participants not at a Regulated Research Institution. If at a Regulated Research Institution,
use institutional approval forms for documentation of prior review and approval.
(IRB approval required before experimentation.)

Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo Uretricity system: an energy converting device using subtrate compound found in urine

Student’s Name(s) Title of Project

Adult Sponsor Contact Phone/Email

Must be completed by Student Researcher(s) in collaboration with the Adult Sponsor/Designated Supervisor/Qualified Scientist:
1. o I have submitted my Research Plan which addresses ALL areas indicated in the Human Participants Section of the Research Plan
Instructions.
2. o I have attached any surveys or questionnaires I will be using in my project or other documents provided to human participants.
o Any published instrument(s) used was /were legally obtained.
3. o I have attached an informed consent that I would use if required by the IRB.
4. o Yes o No Are you working with a Qualified Scientist? If yes, attach the Qualified Scientist Form 2.

BELOW — IRB USE ONLY

Must be completed by Institutional Review Board (IRB) after review of the research plan. All questions must be answered for the
approval to be valid. (If not approved, return paperwork to the student with instructions for modifications.)
o Approved with Full Committee Review (3 signatures required) and the following conditions: (All 5 must be answered)
1. Risk Level (check one) : o Minimal Risk o More than Minimal Risk
2. Qualified Scientist (QS) Required: o Yes o No
3. Designated Supervisor (DS) Required: o Yes o No
4. Written Minor Assent required for minor participants:
o Yes o No o Not applicable (No minors in this study)
5. Written Parental Permission required for minor participants:
o Yes o No o Not applicable (No minors in this study)
6. Written Informed Consent required for participants 18 years or older:
o Yes o No o Not applicable (No participants 18 yrs or older in this study)
o Approved with Expedited Review (1 signature required). Study involves either of the following:
o Human participants will only provide feedback on project design/student-designed invention or prototype. etc., no personal
data will be collected and there are no health or safety hazards.
o Student is the only subject of the research and no more than minimal risk is involved.

IRB SIGNATURES (All 3 signatures required unless expedited review checked above) None of these individuals may be the adult
sponsor, designated supervisor, qualified scientist or related to (e.g., mother, father of) the student (conflict of interest).
I attest that I have reviewed the student’s project, that the checkboxes above have been completed to indicate the IRB determination
and that I agree with the decisions above.
Medical or Mental Health Professional (a psychologist, medical doctor, licensed social worker, licensed clinical professional counselor, physician’s
assistant, or registered nurse)

Printed Name Degree/Professional License

Signature Date of Approval (Must be prior to experimentation.)

Educator

Printed Name Degree

Signature Date of Approval (Must be prior to experimentation.)

School Administrator

Printed Name Degree/Professional License

Signature Date of Approval (Must be prior to experimentation.)

International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef Page 35
 Human Informed Consent Form
Instructions to the Student Researcher(s): An informed consent/assent/permission form should be developed in
consultation with the Adult Sponsor, Designated Supervisor or Qualified Scientist.
This form is used to provide information to the research participant (or parent/guardian) and to document written informed
consent, minor assent, and/or parental permission.
• When written documentation is required, the researcher keeps the original, signed form.
• Students may use this sample form or may copy ALL elements of it into a new document.

If the form is serving to document parental permission, a copy of any survey or questionnaire must be attached.

Student Researcher(s): Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo
Title of Project: Uretricity system: an energy converting device using subtrate compound found in urine

I am asking for your voluntary participation in my science fair project. Please read the following information about the project.
If you would like to participate, please sign in the appropriate area below.

Purpose of the project:

If you participate, you will be asked to:

Time required for participation:

Potential Risks of Study:

Benefits:

How confidentiality will be maintained:

If you have any questions about this study, feel free to contact:

Adult Sponsor/QS/DS: ____________________________________ Phone/email: ____________________

Voluntary Participation:
Participation in this study is completely voluntary. If you decide not to participate there will not be any negative consequences.
Please be aware that if you decide to participate, you may stop participating at any time and you may decide not to answer any
specific question.

By signing this form I am attesting that I have read and understand the information above and I freely give my consent/assent
to participate or permission for my child to participate.

Adult Informed Consent or Minor Assent Date Reviewed & Signed:

Research Participant Printed Name: Signature:

Parental/Guardian Permission (if applicable) Date Reviewed & Signed:

Parent/Guardian Printed Name: Signature:

Page 36 International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef
 Vertebrate Animal Form (5A)
Required for all research involving vertebrate animals that is conducted in a school/home/field research site.
(SRC approval required before experimentation.)

Student’s Name(s) Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Title of Project Uretricity system: an energy converting device using subtrate compound found in urine

To be completed by Student Researcher:

1. Common name (or Genus, species) and number of animals used.

2. Describe completely the housing and husbandry to be provided. Include the cage/pen size, number of animals per
cage, environment, bedding, type of food, frequency of food and water, how often animal is observed, etc. Add an
additional page as necessary.

3. What will happen to the animals after experimentation?

4. Attach a copy of wildlife licenses or approval forms, as applicable

5. The Intel ISEF Vertebrate Animal Rules require that any death, illness or unexpected weight loss be investigated and
documented by a letter from the qualified scientist, designated supervisor or a veterinarian. If applicable, attach this
letter with this form when submitting your paperwork to the SRC prior to competition.

To be completed by Local or Affiliate Fair Scientific Review Committee (SRC) BEFORE experimentation.
Level of Supervision Required for agricultural, behavioral or nutritional studies:
o Designated Supervisor REQUIRED. Please have applicable person sign below.
o Veterinarian and Designated Supervisor REQUIRED. Please have applicable persons sign below.
o
Veterinarian, Designated Supervisor and Qualified Scientist REQUIRED. Please have applicable persons sign below and have the Qualified
Scientist complete Form (2).
The SRC has carefully reviewed this study and finds it is an appropriate study that may be conducted in a non-regulated research site.
Local or Affiliate Fair SRC Pre-Approval Signature:

SRC Chair Printed Name Signature Date of Approval (must be prior to experimentation)
(mm/dd/yy)

To be completed by Veterinarian: To be completed by Designated Supervisor or

Qualified Scientist when applicable:
o I have reviewed this research and animal husbandry with the
student before the start of experimentation. o I have reviewed this research and animal husbandry with
the student before the start of experimentation and I
o I have approved the use and dosages of prescription drugs accept primary responsibility for the care and handling of
and/or nutritional supplements. the animals in this project.
o I will provide veterinary medical and nursing care in case of o I will directly supervise the experiment.
illness or emergency.

Printed Name Email/Phone Printed Name Email/Phone

Signature Date of Approval Signature Date of Approval

International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef Page 37
 Vertebrate Animal Form (5B)
Required for all research involving vertebrate animals that is conducted in at a Regulated Research Institution.
(IACUC approval required before experimentation. Form must be completed and signed after experimentation.)

Student’s Name(s) Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Title of Project Uretricity system: an energy converting device using subtrate compound found in urine
Title and Protocol Number of IACUC Approved Project

To be completed by Qualified Scientist or Principal Investigator:

1. Species of animals used: Number of animals used:

2. Describe, in detail, the role of the student in this project: animal procedures and related equipment that were
involved, oversight provided and safety precautions employed. (Attach extra pages if necessary.)

3. Was there any weight loss or death of any animal? If yes, attach a letter obtained from the qualified scientist,
designated supervisor or a veterinarian documenting the situation and the results of the investigation.

4. Did the student’s project also involve the use of tissues?

p No
p Yes; complete Forms 6A and 6B

5. What laboratory training, including dates, was provided to the student?

6. Attach a copy of the Regulated Research Institution IACUC Approval. A letter from the Qualified Scientist or
Principal Investigator is not sufficient.

Qualified Scientist/Principal Investigator

Printed Name

Signature Date

Page 38 International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef
 Potentially Hazardous Biological Agents Risk Assessment Form (6A)
Required for research involving microorganisms, rDNA, fresh/frozen tissue (including primary cell lines, human and
other primate established cell lines and tissue cultures), blood, blood products and body fluids.
SRC/IACUC/IBC approval required before experimentation.

Student’s Name(s) Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Title of Project Uretricity system: an energy converting device using subtrate compound found in urine
To be completed by Student Researcher(s) in collaboration with Qualified Scientist/Designated Supervisor:
(All questions are applicable and must be answered; additional page(s) may be attached.)

1. Identify potentially hazardous biological agents to be used in this experiment. Include the source, quantity and the biosafety level
risk group of each microorganism.

2. Describe the site of experimentation including the level of biological containment.

3. Describe the procedures that will be used to minimize risk (personal protective equip., hood type, etc.).

4. What final biosafety level do you recommend for this project given the risk assessment you conducted?

5. Describe the method of disposal of all cultured materials and other potentially hazardous biological agents.

To be completed by Qualified Scientist or Designated Supervisor

1. What training will the student receive for this project?
2. Do you concur with the biosafety information and recommendation provided by the student researcher above?
o Yes o No If no, please explain.
3. Experience/training of Designated Supervisor as it relates to the student’s area of research (if applicable)

QS/DS Printed Name Signature Date of Signature (mm/dd/yy)

To be completed by Local or Affiliate Fair SRC: (Check all that apply.)

o The SRC has carefully studied this project’s Research Plan and the risk level assessment above prior to experimentation and
approves this study as a BSL-1 study, which must be conducted at a BSL-1 or above laboratory.
Date of SRC approval (prior to experimentation) _____________________
o The SRC has carefully studied this project’s Research Plan and the risk level assessment above prior to experimentation and
approves this study as a BSL-2 study, which must be conducted at a BSL-2 or above laboratory.
Date of SRC approval (prior to experimentation) _____________________
o This project was conducted at a Research Institution and was reviewed and approved by the appropriate institutional board
(e.g. IACUC, IBC) before experimentation at a BSL-1 or BSL-2 laboratory and complies with the Intel ISEF rules. The required
institutional forms are attached.
Date of SRC approval (after experimentation) _________________________________

o The Research Institution where this study was conducted does not require approval for this type of study. Attached is
institutional documentation certifying the above. The student has received proper training and the project complies with Intel
ISEF rules.
Date of SRC approval ______________________________________________________

SRC Chair’s Printed Name Signature

International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef Page 39
 Human and Vertebrate Animal Tissue Form (6B)
Required for research involving fresh/frozen tissue (including primary cell lines, human and other primate established cell lines and
tissue cultures), blood, blood products and body fluids. If the research involves living organisms please ensure that the proper human
or animal forms are completed. All projects using any tissue listed above must also complete Form 6A.

Student’s Name(s) Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Title of Project Uretricity system: an energy converting device using subtrate compound found in urine

To be completed by Student Researcher(s):

1. What vertebrate animal tissue will be used in this study? Check all that apply.
o Fresh or frozen tissue sample
o Fresh organ or other body part
o Blood
o Body fluids
o Primary cell/tissue cultures
o Human or other primate established cell lines

2. Where will the above tissue(s) be obtained. If using an established cell line include source and catalog number.

3. If the tissue will be obtained from a vertebrate animal study conducted at a research institution attach a copy of the
IACUC certification with the name of the research institution, the title of the study, the IACUC approval number and
date of IACUC approval.

To be completed by the Qualified Scientist or Designated Supervisor:

o I verify that the student will work solely with organs, tissues, cultures or cells that will be supplied to him/her by myself or
qualified personnel from the laboratory; and that if vertebrate animals were euthanized they were euthanized for a purpose
other than the student’s research.
AND/OR
o I certify that the blood, blood products, tissues or body fluids in this project will be handled in accordance with the standards
and guidance set forth in Occupational Safety and Health Act, 29CFR, Subpart Z, 1910.1030 - Blood Borne Pathogens.

Printed Name Signature Date of Approval

(Must be prior to experimentation.)

Title Phone/Email

Institution

Page 40 International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef
 Continuation/Research Progression Projects Form (7)
Required for projects that are a continuation/progression in the same field of study as a previous project.
This form must be accompanied by the previous year’s abstract and Research Plan.

Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo
Student’s Name(s)

To be completed by Student Researcher:

List all components of the current project that make it new and different from previous research. The
information must be on the form; use an additional form for 2014–2015 and earlier projects.

Current Research Previous Research

Components
Project Project
1. Title 2014–2015

Uretricity system: an energy converting device using subtrate compound found in urine

2013–2014

2. Change in 2014–2015
goal/purpose/
objective 2013–2014

3. Changes in 2014–2015
methodology
2013–2014

4. Variables 2014–2015
studied
2013–2014

5. Additional 2014–2015
changes
2013–2014

Attached are:
o 2014–2015 Abstract and Research Plan o 2013–2014 Abstract

I hereby certify that the above information is correct and that the current year Abstract & Certification and
project display board properly reflect work done only in the current year.
Raven Kyle Josef R. Chua, Braile Toby R. Ibuyat, Julian Adrian S. Gulmayo

Student’s Printed Name(s) Signature Date of Signature

International Rules: Guidelines for Science and Engineering Fairs 2015–2016, student.societyforscience.org/intel-isef Page 41