Humanendorsementform
Humanendorsementform
Humanendorsementform
THIS COMPLETED FORM MUST BE RECEIVED BY NOVEMBER ________________________ (NO FAXED DOCUMENTS ACCEPTED)
This endorsement request MUST be completed on-line at www.cssf.org; and may be saved, printed, signed, scanned and sent to
[email protected].
Read and answer each of the following questions carefully so the Scientific Review Committee can fairly assess whether your
project will be safe for your test subjects. Do NOT copy and attach the procedure from your research plan as a substitute.
2. Briefly describe the proposed procedure, including the length of time in which human subject(s) will be involved.
3. Describe any potential risks or discomforts the subjects may endure in this procedure:
4. Describe what precautions will be taken to prevent or eliminate possible health hazards:
5. Anonymity of test subjects is mandatory. Describe how the identity of your test subjects will be concealed in the research
paper and display board.
6. Describe social distancing precautions and any social media that will be used
THE SIGNATURES OF THE SPONSOR AND THE STUDENT OR STUDENTS BELOW INDICATE THAT THE PROJECT CONFORMS TO
THE ABOVE RULES OF CPS STUDENT SCIENCE FAIR AND OF THE ILLINOIS JUNIOR ACADEMY OF SCIENCE.
Date: ______________________________________________________________
The signature and stamp in blue ink indicate this project has been approved as safe SRC
FOR Stamp: Scientific Review Committee Member:
SRC USE
ONLY
Date of approval:
SIGNATURE AND STAMP FROM THE SRC MUST BE ON THIS ENDORSEMENT BEFORE THIS PROJECT CAN BE EXHIBITED. THIS
ENDORSEMENT MUST BE TYPED AND DISPLAYED ON THE FRONT OF THE EXHIBITOR'S DISPLAY BOARD. DISPLAYED
ENDORSEMENT CAN NOT BE SMALLER THAN 8.5 INCHES (VERTICAL) X 5.5 INCHES (HORIZONTAL). (PRINT AT 75%
REDUCTION)
❑ CHECK BOX IF EXCEPTION/APPROVAL LETTER IS REQUIRED AND ATTACHED (SEE PAGE 14 OF THE HANDBOOK)
INFORMED CONSENT CERTIFICATION
MUST BE TYPED AND SUBMITTED WITH HUMAN AS TEST SUBJECTS ENDORSEMENT FORM
Please see page 12 of the handbook for details.
THIS FORM IS REQUIRED OF SOME PROJECTS INVOLVING HUMANS AS TEST SUBJECTS
C Possible discomforts or risks the subject(s) may reasonably expect through participation in this research:
G Name and phone number of teacher/supervisor who can provide information regarding this research :
_________________________________________________________________________________________ ( ____
EMAIL AREA C
NAME
AS A TEST SUBJECT:
I have read and understand the conditions stated above, that participation in this research procedure is completely
voluntary. I am free to withdraw my consent and to discontinue participation in this research activity at any time
without any negative consequences
Parent's or guardian's signature if test subject is a minor (under age 18) or a protected special needs person.
If this research is under the supervision of a qualified scientist (not including the teacher or student):
Institution : ________________________________________________________________________
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