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(%5A'-$1 "#$% &'


Check||sI fcr Adu|I Scnscr (1)
Th|s ccm|eIed fcrm |s requ|red fcr ALL rcjecIs.
AdulI Spcnscr's PrinIed Name SignaIure 0aIe c! Review
Phcne Email
Tc be ccm|eIed by Ihe Adu|I Scnscr |n cc||abcraI|cn w|Ih Ihe sIudenI researcher(s):
SIudenI's Name(s).
PrcjecI TiIle.
1) l have reviewed Ihe lnIel lSEF Rules and Cuidelines.
Z) l have reviewed Ihe sIudenI's ccmpleIed SIudenI ChecklisI (1A) and Research Plan.
3) l have wcrked wiIh Ihe sIudenI and we have discussed Ihe pcssible risks invclved in Ihe prcjecI.
4) The prcjecI invclves cne cr mcre c! Ihe !cllcwing and requires pricr apprcval by an SRC, lRB, lACUC cr lBC.
Humans PcIenIially Hazardcus Biclcgical AgenIs
VerIebraIe Animals Nicrccrganisms r0NA Tissues
5) lIems Ic be ccmpleIed !cr ()) "*+,-./0
AdulI Spcnscr ChecklisI (1) Research Plan
SIudenI ChecklisI (1A) Apprcval Fcrm (1B)
RegulaIed Research lnsIiIuIicnal/lndusIrial SeIIing Fcrm (1C) (when applicable a!Ier ccmpleIed experimenI)
CcnIinuaIicn/Research Prcgressicn Fcrm (7) (when applicable)
6) Add|I|cna| fcrms requ|red |f Ihe rcjecI |nc|udes Ihe use cf cne cr mcre cf Ihe fc||cw|ng (check all IhaI
apply).
Humans (Requires pricr apprcval by an lnsIiIuIicnal Review Bcard (lRB), see !ull IexI c! Ihe rules.)
Human ParIicipanIs Fcrm (4) cr apprcpriaIe lnsIiIuIicnal lRB dccumenIaIicn
Sample c! ln!crmed CcnsenI Fcrm (when applicable and/cr required by Ihe lRB)
0ualied ScienIisI Fcrm (Z) (when applicable and/cr required by Ihe lRB)
VerIebraIe An|ma|s (Requires pricr apprcval, see !ull IexI c! Ihe rules.)
VerIebraIe Animal Fcrm (5A)-!cr prcjecIs ccnducIed in a schccl/hcme/eld research siIe (SRC pricr
apprcval required.)
VerIebraIe Animal Fcrm (5B)-!cr prcjecIs ccnducIed aI a RegulaIed Research lnsIiIuIicn. (lnsIiIuIicnal
Animal Care and Use CcmmiIIee (lACUC) apprcval required pricr experimenIaIicn.)
0ualied ScienIisI Fcrm (Z) (Required !cr all verIebraIe animal prcjecIs aI a regulaIed research siIe cr
when applicable)
PcIenI|a||y Hazardcus |c|cg|ca| AgenIs (Requires pricr apprcval by SRC, lACUC cr lnsIiIuIicnal Bicsa!eIy
CcmmiIIee (lBC), see !ull IexI c! Ihe rules.)
PcIenIially Hazardcus Biclcgical AgenIs Risk AssessmenI Fcrm (6A)
Human and VerIebraIe Animal Tissue Fcrm (6B)-Ic be ccmpleIed in addiIicn Ic Fcrm 6A when prcjecI
invclves Ihe use c! !resh cr !rczen Iissue, primary cell culIures, blccd, blccd prcducIs and bcdy duids.
0ualied ScienIisI Fcrm (Z) (when applicable)

NcIe. CerIain prcjecIs invclving micrccrganisms are exempI !rcm Ihe PHBA review and !crm requiremenIs.
See Ihe !ull IexI !cr deIails
Hazardcus Chem|ca|s, AcI|v|I|es and Dev|ces (Nc pricr apprcval required, see !ull IexI c! Ihe rules.)
Risk AssessmenI Fcrm (3)
0ualied ScienIisI Fcrm (Z) (required !cr prcjecIs invclving 0EAccnIrclled subsIances cr when
applicable)
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SIudenI Check||sI (1A)
Th|s fcrm |s requ|red fcr ALL rcjecIs.
1) a. SIudenI/Team Leader. Crade.
Email. Phcne.
b. Team Nember. c. Team Nember.
Z) TiIle c! PrcjecI.
3) Schccl. Schccl Phcne.
Schccl Address.
4) AdulI Spcnscr. Phcne/Email.
5) ls Ihis a ccnIinuaIicn/prcgressicn !rcm a previcus year Yes Nc
l! Yes.
a) AIIach Ihe previcus year's AbsIracI and Research Plan
b) Explain hcw Ihis prcjecI is new and di!!erenI !rcm previcus years cn CcnIinuaIicn/Research Prcgressicn
Fcrm (7)
6) This year's labcraIcry experimenI/daIa ccllecIicn. (musI be sIaIed (mm/dd/yy))
SIarI 0aIe. (mm/dd/yy) End 0aIe. (mm/dd/yy)
7) where will ycu ccnducI ycur experimenIaIicn (check all IhaI apply)
Research lnsIiIuIicn Schccl Field Hcme
B) LisI name and address c! all ncnschccl wcrk siIe(s).
Name.
Address.
Phcne.
9) Ccm|eIe a Pesearch P|an fc||cw|ng Ihe Pesearch P|an |nsIrucI|cns and aIIach Ic Ih|s fcrm.
10) An absIracI |s requ|red fcr a|| rcjecIs afIer exer|menIaI|cn.
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'%(%#)*+ ",#- .-(/)0*/12-(
A ccm|eIe research |an |s requ|red and musI acccmany Check||sI fcr SIudenI (1A)
Prcv|de a Iyed research |an and aIIach Ic SIudenI Check||sI (1A). P|ease |nc|ude ycur name cn each age.
3+% )%(%#)*+ 4,#- 52) 677 4)28%*/( 1( /2 1-*,09% /+% 52,,2:1-$;
A. uesI|cn cr Prcb|em be|ng addressed
. ca|slExecIed 0uIccmeslHycIheses
C. Descr|I|cn |n deIa|| cf meIhcd cr rccedures (The !cllcwing are impcrIanI and key iIems IhaI shculd be included
when !crmulaIing ANY AN0 ALL research plans.)
")2*%90)%(; 0eIail all prccedures and experimenIal design Ic be used !cr daIa ccllecIicn
P|sk and SafeIy: ldenIi!y any pcIenIial risks and sa!eIy precauIicns Ic be Iaken.
DaIa Ana|ys|s: 0escribe Ihe prccedures ycu will use Ic analyze Ihe daIa/resulIs IhaI answer research quesIicns cr
hypcIheses
D. |b||cgrahy: LisI aI leasI ve (5) majcr re!erences (e.g. science jcurnal arIicles, bccks, inIerneI siIes) !rcm ycur
liIeraIure review. l! ycu plan Ic use verIebraIe animals, cne c! Ihese re!erences musI be an animal care re!erence.
! Chccse cne sIyle and use iI ccnsisIenIly Ic re!erence Ihe liIeraIure used in Ihe research plan
! Cuidelines can be !cund in Ihe SIudenI Handbcck
IIems 1-4 be|cw are subjecIsec|c gu|de||nes fcr add|I|cna| |Iems Ic be |nc|uded |n ycur research |an as
#44,1*#<,%;
1. Human arI|c|anIs research.
"#)/1*14#-/(= 0escribe whc will parIicipaIe in ycur sIudy (age range, gender, racial/eIhnic ccmpcsiIicn). ldenIi!y any
vulnerable pcpulaIicns (mincrs, pregnanI wcmen, priscners, menIally disabled cr eccncmically disadvanIaged).
Pecru|ImenI. where will ycu nd ycur parIicipanIs Hcw will Ihey be inviIed Ic parIicipaIe
>%/+29(= whaI will parIicipanIs be asked Ic dc will ycu use any surveys, quesIicnnaires cr IesIs whaI is Ihe
!requency and lengIh c! Iime invclved !cr each subjecI
P|sk AssessmenI
! P|sks. whaI are Ihe risks cr pcIenIial disccm!crIs (physical, psychclcgical, Iime invclved, sccial, legal, eIc.) Ic
parIicipanIs Hcw will ycu minimize Ihe risks
! eneIs. LisI any beneIs Ic sccieIy cr each parIicipanI.
PrcIecI|cn cf Pr|vacy. will any idenIiable in!crmaIicn (e.g., names, Ielephcne numbers, birIh daIes, email
addresses) be ccllecIed will daIa be ccndenIial cr ancnymcus l! ancnymcus, describe hcw Ihe daIa will be
ccllecIed ancnymcusly. l! ncI ancnymcus, whaI prccedures are in place !cr sa!eguarding ccndenIialiIy where will
Ihe daIa be sIcred whc will have access Ic Ihe daIa whaI will ycu dc wiIh Ihe daIa aI Ihe end c! Ihe sIudy
Infcrmed CcnsenI Prccess. 0escribe hcw ycu will in!crm parIicipanIs abcuI Ihe purpcse c! Ihe sIudy, whaI Ihey
will be asked Ic dc, IhaI Iheir parIicipaIicn is vclunIary and Ihey have Ihe righI Ic sIcp aI any Iime.
Z. VerIebraIe an|ma| research.
Briedy discuss pcIenIial ALTEPNATIVES Ic verIebraIe animal use and presenI a deIailed jusIicaIicn !cr use c!
verIebraIe animals
Explain pcIenIial impacI cr ccnIribuIicn Ihis research may have
0eIail all prccedures Ic be used
! lnclude meIhcds used Ic minimize pcIenIial disccm!crI, disIress, pain and injury Ic Ihe animals during Ihe
ccurse c! experimenIaIicn
! 0eIailed chemical ccncenIraIicns and drug dcsages
0eIail animal numbers, species, sIrain, sex, age, scurce, eIc.
! lnclude jusIicaIicn c! Ihe numbers planned !cr Ihe research
0escribe hcusing and cversighI c! daily care
0iscuss dispcsiIicn c! Ihe animals aI Ihe IerminaIicn c! Ihe sIudy
3. PcIenI|a||y Hazardcus |c|cg|ca| AgenIs.
0escribe Bicsa!eIy Level AssessmenI prccess and resulIanI BSL deIerminaIicn
Cive scurce c! agenI, scurce c! specic cell line, eIc.
0eIail sa!eIy precauIicns
0iscuss meIhcds c! dispcsal
4. Hazardcus Chem|ca|s, AcI|v|I|es & Dev|ces.
0escribe Risk AssessmenI prccess and resulIs
0eIail chemical ccncenIraIicns and drug dcsages
0escribe sa!eIy precauIicns and prccedures Ic minimize risk
0iscuss meIhcds c! dispcsal
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Arcva| Fcrm (1)
A ccmpleIed !crm is required !cr each sIudenI, including all Ieam members.
a) Pequ|red fcr rcjecIs IhaI need r|cr SPClIP
arcva| EF0PE exer|menIaI|cn
(humans, verIebraIes cr pcIenIially hazardcus
biclcgical agenIs)
The SRC/lRB has care!ully sIudied Ihis prcjecI's ($)$"*+,
!-". and all Ihe required !crms are included. Ny signaIure
indicaIes apprcval c! Ihe ($)$"*+, !-". be!cre Ihe
sIudenI begins experimenIaIicn.
SRC/lRB Chair's PrinIed Name
SignaIure 0aIe c! Apprcval (mm/dd/yy)
(NusI be pricr Ic experimenIaIicn.)
!" F|na| InIe| ISEF Af||aIed Fa|r SPC Arcva| (Pequ|red fcr ALL PrcjecIs)
/0 ($123*$4 56* *$)$"*+, +6.42+7$4 "7 "-- ($#2-"7$4
Pesearch InsI|IuI|cns w|Ih nc r|cr fa|r SPClIP
arcva|.
This prcjecI was ccnducIed aI a regulaIed research
insIiIuIicn (ncI hcme cr h|gh schcc|, eIc.), was
reviewed and apprcved by Ihe prcper insIiIuIicnal
bcard be!cre experimenIaIicn and ccmplies wiIh Ihe
lnIel lSEF Rules. 877"+, 9:;0 ".4 *$123*$4 3.)7372736."-
arcva|s (e.g. IACUC, IP).
SRC Chair's PrinIed Name
SignaIure 0aIe c! Apprcval (mm/dd/yy)
SPC Arcva| AfIer Exer|menIaI|cn and efcre CcmeI|I|cn aI Peg|cna|lSIaIelNaI|cna| Fa|r
l cerIi!y IhaI Ihis prcjecI adheres Ic Ihe apprcved ($)$"*+, !-". and ccmplies wiIh all lnIel lSEF Rules.
Regicnal SRC Chair's PrinIed Name SignaIure 0aIe c! Apprcval
SIaIe/NaIicnal SRC Chair's PrinIed Name SignaIure 0aIe c! Apprcval
(where appIicabIe)
$" Tc e Ccm|eIed by SIudenI and ParenI
a) SIudenI Ackncw|edgmenI:
l undersIand Ihe risks and pcssible dangers Ic me c! Ihe prcpcsed research plan.
l have read Ihe lnIel lSEF Rules and Cuidelines and will adhere Ic all lnIernaIicnal Rules when ccnducIing Ihis
research.
l have read and will abide by Ihe !cllcwing EIhics sIaIemenI
Sc|enI|c fraud and m|sccnducI are ncI ccndcned aI any |eve| cf research cr ccmeI|I|cn. Such racI|ces |nc|ude
|ag|ar|sm, fcrgery, use cr resenIaI|cn cf cIher researcher's wcrk as cne's cwn, and fabr|caI|cn cf daIa.
Fraudu|enI rcjecIs w||| fa|| Ic qua||fy fcr ccmeI|I|cn |n af||aIed fa|rs and Ihe InIe| ISEF.
SIudenI's PrinIed Name SignaIure 0aIe Ackncwledged (mm/dd/yy)
(NusI be pricr Ic experimenIaIicn.)
b) ParenIluard|an Arcva|: l have read and undersIand Ihe risks and pcssible dangers invclved in Ihe ($)$"*+,
!-".. l ccnsenI Ic my child parIicipaIing in Ihis research.
ParenI/Cuardian's PrinIed Name SignaIure 0aIe Ackncwledged (mm/dd/yy)
(NusI be pricr Ic experimenIaIicn.)
%" Tc be ccm|eIed by Ihe |cca| cr af||aIed Fa|r SPC
(Pequ|red fcr rcjecIs requ|r|ng r|cr SPClIP APPP0VAL. S|gn Za cr Zb as arcr|aIe.)
<(
!"#$%"&#'("&) +,)$-. /,'0$)'"$- 1(% 23'$"3$ &"0 4"5'"$$%'"5 6&'%- 789:;789<= >>>?-(3'$#@1(%-3'$"3$?(%5A'-$1 "#$% &'
Pegu|aIed Pesearch InsI|IuI|cna|lIndusIr|a| SeII|ng Fcrm (1C)
Th|s fcrm musI be ccm|eIed AFTEP exer|menIaI|cn by Ihe adu|I suerv|s|ng Ihe sIudenI research ccnducIed
|n a regu|aIed research |nsI|IuI|cn, |ndusIr|a| seII|ng cr any wcrk s|Ie cIher Ihan hcme, schcc| cr e|d.
Th|s fcrm HUST be d|s|ayed w|Ih ycur rcjecI, rescnses musI be cn Ihe fcrm.
SIudenI's Name(s)
TiIle c! PrcjecI
Tc be ccm|eIed by Ihe Suerv|s|ng Adu|I |n Ihe SeII|ng (N0T Ihe SIudenI(s)) afIer exer|menIaI|cn:
(Respcnses musI remain cn Ihe !crm as iI is required Ic be displayed aI sIudenI's prcjecI bccIh.)
The sIudenI(s) ccnducIed research aI my wcrk siIe.
a) Ic use Ihe equipmenI b) Ic per!crm experimenI(s)/ccnducI research
1) ls Ihis research a subseI c! ycur wcrk Yes Nc
Z) Have ycu reviewed Ihe lnIel lSEF rules relevanI Ic Ihis prcjecI Yes Nc
3) Hcw did Ihe sIudenI geI Ihe idea !cr her/his prcjecI
(e.g. was Ihe prcjecI assigned, picked !rcm a lisI, an criginal sIudenI idea, eIc.)
4) 0id Ihe sIudenI(s) wcrk cn Ihe prcjecI as a parI c! a research grcup Yes Nc
l! yes, hcw large was Ihe grcup and whaI kind c! research grcup was iI (sIudenIs, grcup c! adulI researchers, eIc.)
5) whaI specic prccedures cr equipmenI did Ihe sIudenI(s) acIually use !cr Ihe prcjecI
Please lisI and describe. (0c ncI lisI prccedures sIudenI cnly cbserved.)
6) Hcw independenI cr creaIive was Ihe sIudenI's/sIudenIs' wcrk
5tudent research projects deaIing with human participants, vertebrate animaIs or potentiaIIy hazardous bioIogicaI
agents require review and approvaI by an institutionaI reguIatory board (lRB/lACUC/lBC). Ccy cf arcva|(s)
musI be aIIached, |f a||cab|e.
Supervising AdulI's PrinIed Name SignaIure TiIle
lnsIiIuIicn 0aIe Signed (musI be a!Ier experimenIaIicn)
Address Email/Phcne
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ua||ed Sc|enI|sI Fcrm (Z)
Hay be requ|red fcr research |nvc|v|ng human arI|c|anIs, verIebraIe an|ma|s, cIenI|a||y hazardcus b|c|cg|ca| agenIs, and
DEAccnIrc||ed subsIances. HusI be ccm|eIed and s|gned befcre Ihe sIarI cf sIudenI exer|menIaI|cn.
Tc be ccm|eIed by Ihe Des|gnaIed Suerv|scr
when Ihe ua||ed Sc|enI|sI canncI d|recI|y
suerv|se.
l cerIi!y IhaI l have reviewed Ihe Research Plan and have
been Irained in Ihe Iechniques Ic be used by Ihis sIudenI,
and l will prcvide direcI supervisicn.
0esignaIed Superviscr's PrinIed Name
SignaIure 0aIe c! Apprcval
Phcne Email
Tc be ccm|eIed by Ihe ua||ed Sc|enI|sI:
l cerIi!y IhaI l have reviewed and apprcved Ihe Research
Plan pricr Ic Ihe sIarI c! Ihe experimenIaIicn. l! Ihe
sIudenI cr 0esignaIed Superviscr is ncI Irained in Ihe
necessary prccedures, l will ensure her/his Iraining. l will
prcvide advice and supervisicn during Ihe research. l
have a wcrking kncwledge c! Ihe Iechniques Ic be used
by Ihe sIudenI in Ihe Research Plan. l undersIand IhaI a
0esignaIed Superviscr is required when Ihe sIudenI is ncI
ccnducIing experimenIaIicn under my direcI supervisicn.
0ualied ScienIisI's PrinIed Name
SignaIure 0aIe c! Apprcval
SIudenI's Name(s)
TiIle c! PrcjecI
Tc be ccm|eIed by Ihe ua||ed Sc|enI|sI:
ScienIisI Name.
EducaIicnal Backgrcund. 0egree(s).
Experience/Training as relaIes Ic Ihe sIudenI's area c! research.
PcsiIicn. lnsIiIuIicn.
Address. Email/Phcne.
1) Have ycu reviewed Ihe lnIel lSEF rules relevanI Ic Ihis prcjecI Yes Nc
Z) will any c! Ihe !cllcwing be used
a) Human parIicipanIs Yes Nc
b) VerIebraIe animals Yes Nc
c) PcIenIially hazardcus biclcgical agenIs (micrccrganisms, r0NA and Iissues,
including blccd and blccd prcducIs) Yes Nc
d) 0EAccnIrclled subsIances Yes Nc
3) was Ihis sIudy a subseI c! a larger sIudy Yes Nc
4) will ycu direcIly supervise Ihe sIudenI Yes Nc
a) l! nc, whc will direcIly supervise and serve as Ihe 0esignaIed Superviscr
b) Experience/Training c! Ihe 0esignaIed Superviscr.
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P|sk AssessmenI Fcrm (3)
Pequ|red fcr rcjecIs us|ng hazardcus chem|ca|s, acI|v|I|es cr dev|ces and m|crccrgan|sms exemI
frcm rearcva|. HusI be ccm|eIed befcre exer|menIaI|cn.
SIudenI's Name(s)
TiIle c! PrcjecI
Tc be ccm|eIed by Ihe SIudenI Pesearcher(s) |n cc||abcraI|cn w|Ih Des|gnaIed Suerv|scrlua||ed
()*%+,*-,. (All quesIicns musI be answered, addiIicnal page(s) may be aIIached.)
1. LisI/idenIi!y micrccrganisms exempI !rcm preapprcval (see PcIenIially Hazardcus Biclcgical AgenI rules),
and all hazardcus chemicals, acIiviIies, cr devices IhaI will be used.
Z. ldenIi!y and assess Ihe risks invclved in Ihis prcjecI.
3. 0escribe Ihe sa!eIy precauIicns and prccedures IhaI will be used Ic reduce Ihe risks.
4. 0escribe Ihe dispcsal prccedures IhaI will be used (when applicable).
5. LisI Ihe scurce(s) c! sa!eIy in!crmaIicn.
Tc be ccm|eIed and s|gned by Ihe Des|gnaIed Suerv|scr (cr ua||ed Sc|enI|sI, when a||cab|e):
l agree wiIh Ihe risk assessmenI and sa!eIy precauIicns and prccedures described abcve. l cerIi!y IhaI l have reviewed Ihe
Research Plan and will prcvide direcI supervisicn.
0esignaIed Superviscr's PrinIed Name SignaIure 0aIe c! Review (mm/dd/yy)
PcsiIicn & lnsIiIuIicn Phcne cr email ccnIacI in!crmaIicn
Experience/Training as relaIes Ic Ihe sIudenI's area c! research
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Human ParI|c|anIs Fcrm (4)
Required !cr all research invclving human parIicipanIs ncI aI a RegulaIed Research lnsIiIuIicn. l! aI a RegulaIed Research lnsIiIuIicn,
use insIiIuIicnal apprcval !crms !cr dccumenIaIicn c! pricr review and apprcval.
(lRB apprcval required be!cre experimenIaIicn.)
SIudenI's Name(s) TiIle c! PrcjecI
AdulI Spcnscr CcnIacI Phcne/Email
HusI be ccm|eIed by SIudenI Pesearcher(s) |n cc||abcraI|cn w|Ih Ihe Adu|I ScnscrlDes|gnaIed Suerv|scrlua||ed
()*$+,*-,.
1. l have submiIIed my Research Plan which addresses ALL areas indicaIed in Ihe Human ParIicipanIs SecIicn c! Ihe
Research Plan lnsIrucIicns.
Z. l have aIIached any surveys cr quesIicnnaires l will be using in my prcjecI.
Any published insIrumenI(s) used was /were legally cbIained.
3. l have aIIached an in!crmed ccnsenI IhaI l wculd use i! required by Ihe lRB.
4. Yes Nc Are ycu wcrking wiIh a 0ualied ScienIisI l! yes, aIIach Ihe 0ualied ScienIisI Fcrm Z
HusI be ccm|eIed by InsI|IuI|cna| Pev|ew card (IP) afIer rev|ew cf Ihe research |an. The submiIIed
Research Plan musI address all areas indicaIed cn Ihe Human ParIicipanIs secIicn c! Ihe Research Plan lnsIrucIicns.
Check cne cf Ihe fc||cw|ng:
Research prcjecI requires revisicns and is N0T arcved aI Ihis Iime. lRB will aIIach dccumenI indicaIing ccncerns
and/cr requesIed revisicns.
Research prcjecI is Arcved wiIh Ihe !cllcwing ccndiIicns belcw. (A|| 5 musI be answered)
1. Risk Level (check cne) . Ninimal Risk Ncre Ihan Ninimal Risk
Z. 0ualied ScienIisI (0S) Required. Yes Nc
3. wriIIen Nincr AssenI required !cr mincr parIicipanIs.
Yes Nc NcI applicable (Nc mincrs in Ihis sIudy)
4. wriIIen ParenIal Permissicn required !cr mincr parIicipanIs.
Yes Nc NcI applicable (Nc mincrs in Ihis sIudy)
5. wriIIen ln!crmed CcnsenI required !cr parIicipanIs 1B years cr clder.
Yes Nc NcI applicable (Nc parIicipanIs 1B yrs cr clder in Ihis sIudy)
IP SINATUPES (A|| 3 s|gnaIures requ|red) Ncne c! Ihese individuals may be Ihe adulI spcnscr, designaIed superviscr,
qualied scienIisI cr relaIed Ic (e.g., mcIher, !aIher c!) Ihe sIudenI (ccndicI c! inIeresI).
I aIIesI IhaI I have rev|ewed Ihe sIudenI's rcjecI and agree w|Ih Ihe abcve IP deIerm|naI|cns.
/$0*)"1 23 /$+,"1 4$"1,5 !326$--*2+"1 (a sychc|cg|sI, med|ca| dccIcr, ||censed scc|a| wcrker, ||censed c||n|ca| rcfess|cna|
ccunse|cr, hys|c|an's ass|sIanI, cr reg|sIered nurse)
Schcc| Adm|n|sIraIcr
PrinIed Name 0egree/Prc!essicnal License
SignaIure 0aIe c! Apprcval (NusI be pricr Ic experimenIaIicn.)
PrinIed Name 0egree
SignaIure 0aIe c! Apprcval (NusI be pricr Ic experimenIaIicn.)
708)",23
PrinIed Name 0egree
SignaIure 0aIe c! Apprcval (NusI be pricr Ic experimenIaIicn.)
!"#$%"&#'("&) +,)$-. /,'0$)'"$- 1(% 23'$"3$ &"0 4"5'"$$%'"5 6&'%- 789:;789<= >>>?-(3'$#@1(%-3'$"3$?(%5A'-$1 "#$% &'
Human Infcrmed CcnsenI Fcrm
()*+,-.+/0)* +0 +1% 2+-3%)+ 4%*%#,.1%,5*67 An in!crmed ccnsenI/assenI/permissicn !crm shculd be develcped in
ccnsulIaIicn wiIh Ihe AdulI Spcnscr, 0esignaIed Superviscr cr 0ualied ScienIisI.
This !crm is used Ic prcvide in!crmaIicn Ic Ihe research parIicipanI (cr parenI/guardian) and Ic dccumenI wriIIen
in!crmed ccnsenI, mincr assenI, and/cr parenIal permissicn.
when wriIIen dccumenIaIicn is required, Ihe researcher keeps Ihe criginal, signed !crm.
SIudenIs may use Ihis sample !crm cr may ccpy ALL elemenIs c! iI inIc a new dccumenI.
l! Ihe !crm is serving Ic dccumenI parenIal permissicn, a ccpy c! any survey cr quesIicnnaire musI be aIIached.
SIudenI Researcher(s).
TiIle c! PrcjecI.
l am asking !cr ycur vclunIary parIicipaIicn in my science !air prcjecI. Please read Ihe !cllcwing in!crmaIicn abcuI Ihe
prcjecI. l! ycu wculd like Ic parIicipaIe, please sign in Ihe apprcpriaIe bcx belcw.
Purpcse c! Ihe prcjecI.
l! ycu parIicipaIe, ycu will be asked Ic.
Time required !cr parIicipaIicn.
PcIenIial Risks c! SIudy.
BeneIs.

Hcw ccndenIialiIy will be mainIained.
l! ycu have any quesIicns abcuI Ihis sIudy, !eel !ree Ic ccnIacI.
AdulI Spcnscr. __________________________ Phcne/email. ____________________________________________
809-)+#,: "#,+/./;#+/0)7
ParIicipaIicn in Ihis sIudy is ccmpleIely vclunIary. l! ycu decide ncI Ic parIicipaIe Ihere will ncI be any negaIive
ccnsequences. Please be aware IhaI i! ycu decide Ic parIicipaIe, ycu may sIcp parIicipaIing aI any Iime and ycu may
decide ncI Ic answer any specic quesIicn.
By signing Ihis !crm l am aIIesIing IhaI l have read and undersIand Ihe in!crmaIicn abcve and l !reely give my
ccnsenI/assenI Ic parIicipaIe cr permissicn !cr my child Ic parIicipaIe.
Adu|I Infcrmed CcnsenI cr H|ncr AssenI 0aIe Reviewed & Signed.
PrinIed Name c! Research ParIicipanI. SignaIure.
ParenIa|luard|an Perm|ss|cn (i! applicable) 0aIe Reviewed & Signed.
ParenI/Cuardian PrinIed Name. SignaIure.
!"#$ &' !"#$%"&#'("&) +,)$-. /,'0$)'"$- 1(% 23'$"3$ &"0 4"5'"$$%'"5 6&'%- 789:;789<= >>>?-(3'$#@1(%-3'$"3$?(%5A'-$1
VerIebraIe An|ma| Fcrm (5A)
Pequ|red fcr a|| research |nvc|v|ng verIebraIe an|ma|s IhaI |s ccnducIed |n a schcc|lhcmele|d research s|Ie.
(SPC arcva| requ|red befcre exer|menIaI|cn.)
SIudenI's Name(s)
TiIle c! PrcjecI
Tc be ccm|eIed by SIudenI Pesearcher:
1. Ccmmcn name (cr Cenus, species) and number c! animals used.
Z. 0escribe ccmpleIely Ihe hcusing and husbandry Ic be prcvided. lnclude Ihe cage/pen size, number c! animals per
cage, envircnmenI, bedding, Iype c! !ccd, !requency c! !ccd and waIer, hcw c!Ien animal is cbserved, eIc.
3. whaI will happen Ic Ihe animals a!Ier experimenIaIicn
4. AIIach a ccpy c! wildli!e licenses cr apprcval !crms, as applicable
5. The lnIel lSEF VerIebraIe Animal Rules require IhaI any deaIh, illness cr unexpecIed weighI lcss be invesIigaIed and
dccumenIed by a leIIer !rcm Ihe qualied scienIisI, designaIed superviscr cr a veIerinarian. l! applicable, aIIach Ihis
leIIer wiIh Ihis !crm when submiIIing ycur paperwcrk Ic Ihe SRC pricr Ic ccmpeIiIicn.
Tc be ccm|eIed by Lcca| cr Af||aIe Fa|r Sc|enI|c Pev|ew Ccmm|IIee (SPC) EF0PE exer|menIaI|cn
Leve| cf Suerv|s|cn Pequ|red fcr agr|cu|Iura|, behav|cra| cr nuIr|I|cna| sIud|es:
0esignaIed Superviscr RE0UlRE0. Please have applicable perscn sign belcw.
VeIerinarian and 0esignaIed Superviscr RE0UlRE0. Please have applicable perscns sign belcw.
VeIerinarian, 0esignaIed Superviscr and 0ualied ScienIisI RE0UlRE0. Please have applicable perscns sign belcw and have Ihe
0ualied ScienIisI ccmpleIe Fcrm (Z).
The SRC has care!ully reviewed Ihis sIudy and nds iI is an apprcpriaIe sIudy IhaI may be ccnducIed in a ncnregulaIed research siIe.
Lcca| cr Af||aIe Fa|r SPC PreArcva| S|gnaIure:
SRC Chair PrinIed Name SignaIure 0aIe c! Apprcval (musI be pricr Ic
experimenIaIicn) (mm/dd/yy)
PrinIed Name Email/Phcne PrinIed Name Email/Phcne
SignaIure 0aIe c! Apprcval SignaIure 0aIe c! Apprcval
Tc be ccm|eIed by VeIer|nar|an:
l cerIi!y IhaI l have reviewed Ihis research and animal
husbandry wiIh Ihe sIudenI be!cre Ihe sIarI c!
experimenIaIicn.
l cerIi!y IhaI l have apprcved Ihe use and dcsages c!
prescripIicn drugs and/cr nuIriIicnal supplemenIs.
l cerIi!y IhaI l will prcvide veIerinary medical and nursing
care in case c! illness cr emergency.
Tc be ccm|eIed by Des|gnaIed Suerv|scr cr
ua||ed Sc|enI|sI when a||cab|e:
l cerIi!y IhaI l have reviewed Ihis research and animal
husbandry wiIh Ihe sIudenI be!cre Ihe sIarI c!
experimenIaIicn and l accepI primary respcnsibiliIy !cr Ihe
care and handling c! Ihe animals in Ihis prcjecI.
l cerIi!y IhaI l will direcIly supervise Ihe experimenI.
!"#$%"&#'("&) +,)$-. /,'0$)'"$- 1(% 23'$"3$ &"0 4"5'"$$%'"5 6&'%- 789:;789<= >>>?-(3'$#@1(%-3'$"3$?(%5A'-$1 "#$% &'
SIudenI's Name(s)
TiIle c! PrcjecI
TiIle and PrcIcccl Number c! lACUC Apprcved PrcjecI
Tc be ccm|eIed by ua||ed Sc|enI|sI cr Pr|nc|a| InvesI|gaIcr:
1. Species c! animals used. Number c! animals used.
Z. 0escribe, in deIail, Ihe rcle c! Ihe sIudenI in Ihis prcjecI. animal prccedures and relaIed equipmenI IhaI were
invclved, cversighI prcvided and sa!eIy precauIicns emplcyed. (AIIach exIra pages i! necessary.)
3. was Ihere any weighI lcss cr deaIh c! any animal l! yes, aIIach a leIIer cbIained !rcm Ihe qualied scienIisI,
designaIed superviscr cr a veIerinarian dccumenIing Ihe siIuaIicn and Ihe resulIs c! Ihe invesIigaIicn.
4. 0ces Ihe sIudenI's prcjecI alsc invclve Ihe use c! Iissues
Nc
Yes, Be sure Ic ccmpleIe Fcrms 6A and 6B
5. whaI labcraIcry Iraining, including daIes, was prcvided Ic Ihe sIudenI
6. AIIach a ccy cf Ihe Pegu|aIed Pesearch InsI|IuI|cn IACUC Arcva|. A leIIer !rcm Ihe 0ualied ScienIisI cr
Principal lnvesIigaIcr is ncI su!cienI(
VerIebraIe An|ma| Fcrm (5)
Pequ|red fcr a|| research |nvc|v|ng verIebraIe an|ma|s IhaI |s ccnducIed |n aI a Pegu|aIed Pesearch InsI|IuI|cn.
(IACUC arcva| requ|red befcre exer|menIaI|cn.)
ua||ed Sc|enI|sIlPr|nc|a| InvesI|gaIcr
PrinIed Name
SignaIure 0aIe
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SIudenI's Name(s)
TiIle c! PrcjecI
Tc be ccm|eIed by SIudenI Pesearcher(s) |n cc||abcraI|cn w|Ih ua||ed Sc|enI|sIlDes|gnaIed Suerv|scr:
(A|| quesI|cns are a||cab|e and musI be answered, add|I|cna| age(s) may be aIIached.)
1. ldenIi!y pcIenIially hazardcus biclcgical agenIs Ic be used in Ihis experimenI. lnclude Ihe scurce, quanIiIy and Ihe bicsa!eIy
level risk grcup c! each micrccrganism.
Z. 0escribe Ihe siIe c! experimenIaIicn including Ihe level c! biclcgical ccnIainmenI.
3. 0escribe Ihe prccedures IhaI will be used Ic minimize risk. (perscnal prcIecIive equip., hccd Iype, eIc.)
4. whaI nal bicsa!eIy level dc ycu reccmmend !cr Ihis prcjecI given Ihe risk assessmenI ycu ccnducIed
5. 0escribe Ihe meIhcd c! dispcsal c! all culIured maIerials and cIher pcIenIially hazardcus biclcgical agenIs.
PcIenI|a||y Hazardcus |c|cg|ca| AgenIs P|sk AssessmenI Fcrm (6A)
Required !cr research invclving micrccrganisms, r0NA, !resh/!rczen Iissue (including primary cell lines, human and
cIher primaIe esIablished cell lines and Iissue culIures), blccd, blccd prcducIs and bcdy duids.
SRC/lACUC/lBC apprcval required be!cre experimenIaIicn.
Tc be ccm|eIed by Lcca| cr Af||aIe Fa|r SPC: (Check a|| IhaI a|y.)
The SRC has care!ully sIudied Ihis prcjecI's Research Plan and Ihe risk level assessmenI abcve r|cr Ic exer|menIaI|cn
and apprcves Ihis sIudy as a BSL1 sIudy, which musI be ccnducIed aI a BSL1 cr abcve labcraIcry.
0aIe c! SRC apprcval (pricr Ic experimenIaIicn) _____________________
The SRC has care!ully sIudied Ihis prcjecI's Research Plan and Ihe risk level assessmenI abcve r|cr Ic exer|menIaI|cn
and apprcves Ihis sIudy as a BSLZ sIudy, which musI be ccnducIed aI a BSLZ cr abcve labcraIcry.
0aIe c! SRC apprcval (pricr Ic experimenIaIicn) _____________________
This prcjecI was ccnducIed aI a Research lnsIiIuIicn and was reviewed and apprcved by Ihe apprcpriaIe insIiIuIicnal
bcard (e.g. lACUC, lBC) be!cre experimenIaIicn aI a BSL1 cr BSLZ labcraIcry and ccmplies wiIh Ihe lnIel lSEF rules. The
required insIiIuIicnal !crms are aIIached.
0aIe c! SRC apprcval (a!Ier experimenIaIicn) _____________________
The Research lnsIiIuIicn where Ihis sIudy was ccnducIed dces ncI require apprcval !cr Ihis Iype c! sIudy. The sIudenI
has received prcper Iraining and Ihe prcjecI ccmplies wiIh lnIel lSEF rules. AIIached is insIiIuIicnal dccumenIaIicn
cerIi!ying Ihe abcve.
0aIe c! SRC apprcval _________________________________________
SRC Chair's PrinIed Name SignaIure
Tc be ccm|eIed by ua||ed Sc|enI|sI cr Des|gnaIed Suerv|scr
1. whaI Iraining will Ihe sIudenI receive !cr Ihis prcjecI
Z. 0c ycu ccncur wiIh Ihe bicsa!eIy in!crmaIicn and reccmmendaIicn prcvided by Ihe sIudenI researcher abcve
Yes Nc l! nc, please explain.
3. Experience/Iraining c! 0esignaIed Superviscr as iI relaIes Ic Ihe sIudenI's area c! research (i! applicable)
0S/0S PrinIed Name SignaIure 0aIe c! SignaIure (mm/dd/yy)
!"#$%"&#'("&) +,)$-. /,'0$)'"$- 1(% 23'$"3$ &"0 4"5'"$$%'"5 6&'%- 789:;789<= >>>?-(3'$#@1(%-3'$"3$?(%5A'-$1 "#$% &'
Human and VerIebraIe An|ma| T|ssue Fcrm (6)
Required !cr research invclving !resh/!rczen Iissue (including primary cell lines, human and cIher primaIe esIablished cell lines
and Iissue culIures), blccd, blccd prcducIs and bcdy duids. l! Ihe research invclves living crganisms please ensure IhaI Ihe prcper
human cr animal !crms are ccmpleIed. All prcjecIs using any Iissue lisIed abcve musI alsc ccmpleIe Fcrm 6A.
SIudenI's Name(s)
TiIle c! PrcjecI
Tc be ccm|eIed by SIudenI Pesearcher(s):
1. whaI verIebraIe animal Iissue will be used in Ihis sIudy Check all IhaI apply.
Fresh cr !rczen Iissue sample
Fresh crgan cr cIher bcdy parI
Blccd
Bcdy duids
Primary cell/Iissue culIures
Human cr cIher primaIe esIablished cell lines
Z. where will Ihe abcve Iissue(s) be cbIained. l! using an esIablished cell line include scurce and caIalcg number.
3. l! Ihe Iissue will be cbIained !rcm a verIebraIe animal sIudy ccnducIed aI a research insIiIuIicn aIIach a ccpy c! Ihe
lACUC cerIicaIicn wiIh Ihe name c! Ihe research insIiIuIicn, Ihe IiIle c! Ihe sIudy, Ihe lACUC apprcval number and
daIe c! lACUC apprcval.
Tc be ccm|eIed by Ihe ua||ed Sc|enI|sI cr Des|gnaIed Suerv|scr:
l veri!y IhaI Ihe sIudenI will wcrk sclely wiIh crgans, Iissues, culIures cr cells IhaI will be supplied Ic him/her by mysel!
cr qualied perscnnel !rcm Ihe labcraIcry, and IhaI i! verIebraIe animals were euIhanized Ihey were euIhanized !cr a
purpcse cIher Ihan Ihe sIudenI's research.
ANDl0P
l cerIi!y IhaI Ihe blccd, blccd prcducIs, Iissues cr bcdy duids in Ihis prcjecI will be handled in acccrdance wiIh Ihe
sIandards and guidance seI !crIh in 0ccupaIicnal Sa!eIy and HealIh AcI, Z9CFR, SubparI Z, 1910.1030 Blccd Bcrne
PaIhcgens.
PrinIed Name SignaIure 0aIe c! Apprcval
(NusI be pricr Ic experimenIaIicn.)

TiIle Phcne/Email
lnsIiIuIicn
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CcnI|nuaI|cnlPesearch Prcgress|cn PrcjecIs Fcrm (7)
Pequ|red fcr rcjecIs IhaI are a ccnI|nuaI|cnlrcgress|cn |n Ihe same e|d cf sIudy as a rev|cus rcjecI.
BC'- 1(%D D,-# E$ &33(DF&"'$0 E@ #C$ F%$G'(,- @$&%H- &E-#%&3# &"0 +$-$&%3C I)&"?
SIudenI's Name(s)
Tc be ccm|eIed by SIudenI Pesearcher:
LisI all ccmpcnenIs c! Ihe currenI prcjecI IhaI make iI new and di!!erenI !rcm previcus research. The in!crmaIicn musI
be cn Ihe !crm, use an addiIicnal !crm !cr Z010-Z011 and earlier prcjecIs.
CcmcnenIs
'())$*+ ,$-$")./
!)01$.+
Prev|cus Pesearch
!)01$.+
1. TiIle
Z01Z-Z013
Z011-Z01Z
Z. Change in
gcal/purpcse/
cbjecIive
Z01Z-Z013
Z011-Z01Z
3. Changes in
meIhcdclcgy
Z01Z-Z013
Z011-Z01Z
4. Variables
sIudied
Z01Z-Z013
Z011-Z01Z
5. AddiIicnal
changes
Z01Z-Z013
Z011-Z01Z
l hereby cerIi!y IhaI Ihe abcve in!crmaIicn is ccrrecI and IhaI Ihe currenI year AbsIracI & CerIicaIicn and
prcjecI display bcard prcperly redecI wcrk dcne cnly in Ihe currenI year.
SIudenI's PrinIed Name(s) SignaIure 0aIe c! SignaIure
AIIached are.
Z01Z-Z013 AbsIracI and Research Plan Z011-Z01Z AbsIracI