Humanendorsementform

Download as pdf or txt
Download as pdf or txt
You are on page 1of 3

COVID VIRUS PRECAUTIONS MUST BE USED

REQUEST FOR HUMANS AS TEST SUBJECTS ENDORSEMENT


BEFORE beginning any project using humans as the subject of an experiment, students must obtain permission from the Scientific Review
Committee and in some cases, from IJAS. Details about rules regarding the use of humans as test subjects are on pages 12-13 of the current STEM
Exhibition Handbook. Only projects that do not cause pain and suffering to humans will be allowed.
THESE RULES WILL BE STRICTLY ENFORCED FOR THE REGIONAL (NETWORK), CITY AND STATE SCIENCE EXPOSITIONS. NO
REGIONAL (NETWORK) EXHIBITION SHALL SEND A PROJECT TO THE CITY OR STATE EXPOSITION THAT DOES NOT MEET THESE
REGULATIONS
1. Humans must not be subjected to treatments that are considered hazardous and/or that could result in undue stress, injury, or death to the subject.
2. NO primary or secondary cultures taken directly (mouth, throat, skin, etc) or indirectly (eating utensils, countertops, doorknobs, toilets, etc.) will
be allowed. However, cultures obtained from reputable biological suppliers or research facilities are suitable for student use.
3. Quantities of food and non-alcoholic beverages are limited to normal serving amounts or less and must be consumed in a reasonable amount of
time. Normal serving amounts must be substantiated with reliable documentation. This documentation must be attached to this endorsement
request. No project may use over-the-counter, prescription, illegal drugs or alcohol in order to measure their effect on a person.
4. The only human blood that may be used is that which is obtained from a blood bank, hospital, or laboratory. No blood may be drawn by any
person or from any person specifically for a science project. This rule does not preclude a student making use of data collected from blood tests
not made exclusively for a science project.
5. Projects that involve exercise and its effect on pulse, respiration rate, blood pressure, and so on are allowed provided the exercise is not carried to
the extreme. Electrical stimulation is not permitted. A valid, normal physical examination report must be on file for each test subject.
Documentation of same must be attached to this endorsement.
6. Projects that involve learning, ESP, motivation, hearing, vision and surveys require the Humans as Test Subjects endorsement
7. ALL SOCIAL DISTANCING PRECAUTIONS MUST BE TAKEN.
If the SRC determines that the proposed procedure involves discomforts or risks (physical, psychological, social, and/or legal) to the test subjects,
each subject must sign an informed consent certification (see page 65 of this handbook. If the subject is under 18 years of age, the permission of
his/her legal guardian must be obtained before the subject may be involved in the experiment. The SRC will indicate next to the committee member's
signature on this form whether the project requires the test subjects to provide informed consent.
EXCEPTIONS to the six rules above will not be allowed unless the student is working with a university, hospital or research facility on an ongoing
research project being conducted by the institution and the following conditions are met. 1) The endorsement request is made before the
SRC deadline of November __________________________)The consulting scientist completes and signs the appropriate section of this
request form and includes the required documentation and 3) The endorsement is granted before the student begins the experiment.
SPECIAL NOTE: Students in grades 9-12 wishing to participate at the International Science and Engineering Fair should consult page 41 of this handbook
for required forms. ISEF rules and forms are available at: https://student.societyforscience.org/international-rules-pre-college-science-research .

Name of Student: _____________________________________________ Student E-mail Address: ________________________________________

Student School ID number (8 digits): Print Name of Teacher-Sponsor _________________________________________

Teacher-Sponsor E-mail Address: ___

School: ___________________________________________________________ GSR# ____________ Date submitted: _______________________


If the proposed experiment or project is being conducted under the supervision of a professor or scientist at a university, hospital
I
or research facility the following information must be submitted with this endorsement request on separate institution letter head.
1
Due by November ______________________

1.Consultant's contact information:

Name of consulting professional: __________________________________________ Title:

Profession: Position and name of Institution:

Phone number (extension if applicable): __________________ E-mail address: ___________________________________________


2. A signed original letter on institute stationery that specifically describes the student's procedure and how the student will be supervised by
the consultant throughout the experiment. The letter must also include the following statement indicating the consulting adult certifies
he/she will provide necessary supervision.
3. A copy of your institution's Institutional Review Board approval that covers the scope of this work, whether original or part of an ongoing
study.
"By signing this document I certify that I will directly train and supervise this student and take necessary precautions to avoid risk to the test
subjects and to the student experimenter."
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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].

(Continued on next page)


PAGE 2 of REQUEST FOR HUMANS AS TEST SUBJECTS ENDORSEMENT
Students and sponsors using humans as test subjects in a science project must complete this form.The signature of the
student(s) and the sponsor indicate the project was done within the rules on the previous page. Failure to comply with these rules
will mean disqualification of the project. This form must follow the Safety Sheet in the project research paper.

Title of Project: ________________________________________________________________________________

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.

1. Hypothesis or problem to be studied (include independent and dependent variables):

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.

Sponsor Signature: ___________________________________________________ Sponsor Email address:

Student 1 Name:_____________________________________________________ Student Email address:

Student 2 Name: ________________________________________________ Student Email address: ______________________

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

Research Project Title: ___________________________________________________________________________

A Purpose of the project:

B Participants will be asked to:

C Possible discomforts or risks the subject(s) may reasonably expect through participation in this research:

D Procedures to be used to minimize risks

E Describe social distancing precautions and social media used

F Possible benefits the test subject(s) might reasonably expect:

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

Test Subject's Signature: ____________________________________________ Date: _______________

Parent's or guardian's signature if test subject is a minor (under age 18) or a protected special needs person.

Parent/Guardian's Signature: _____________________________________________ Date: _________________

If this research is under the supervision of a qualified scientist (not including the teacher or student):

Qualified Scientist's Signature: ________________________________________ Date: _______________

Institution : ________________________________________________________________________

SAVE PRINT

You might also like