Professional Documents
Culture Documents
PROJECT PROPOSAL / STUDENT INFORMATION FORM
This document must be completed by ALL students. All fields must be completed
human vertebrate animals, recombinant DNA, tissues, pathogenic agents, or controlled substances will
need to complete additional forms provided later by the program.
This form must be completed and filed no later than December 15, 2017.
If you have any questions, please contact Ann Miller at amiller@uci.edu.
When completed, email this form to: Ann Miller amiller@uci.edu
Student's Name: ______________________________________________________________________
Name of School: ______________________________________Grade level:
Home/Mobile Phone #: _________________________________________________________________
Email address: _______________________________________________________________________
Where did you conduct your experimentation?
At a research institution: e.g. university lab, medical center, industrial setting: ________
Name of Research Institution:
Lead Researcher’s signature:
Check here _____ if your project involves humans.
Check here _____ if your project involves nonhuman vertebrates
Check here _____ if your project involved bacteria or invertebrates
Check here _____ if your project involves recombinant DNA, pathogenic agents, or controlled
Check here _____ if your project involves human or animal
Name of current High School Science Teacher:
Teacher’s email address:
Teacher’s Signature: Date:
Student's Signature: _________________________________ Date: _____________________________