Hazardous Materials Form 3 (4-8)

Grades 4-8

Required for all research involving hazardous chemicals or devices (not routinely used in class), radiation, controlled or prescription substances, alcohol or tobacco.

Firearms and explosives are not allowed for students in Grades 4 through 8

Note: Kansas State Science and Engineering Fair Review Committee (KSSEFRC) approval required before experiment begins

To obtain approval, fax this completed form directly to 620-583-8222.

Student’s Name_______________________________________________________________________

Title of Project________________________________________________________________________

To be completed by Student Researcher and/or Adult Sponsor (answer on attached page if needed):

1.      Describe the purpose of this study.

2.      List all hazardous materials and how they will be used in this experiment.

3.      Describe and assess any potential risks (toxicity, flammability, reactivity, corrosiveness, etc.) that may occur when working with these hazardous materials-information should be available in MSDS or related materials.

4.      Describe procedures to minimize risk and identify the specific location at which these materials will be used.  Identify who will directly supervise the student’s work and all methods of disposal (if applicable).

All Signatures Required Prior to Start of Research Project

_______________________________  ________________________________  ____________________

Student Research Printed Name                       Signature                                              Date Signed

_______________________________  _______________________________  _____________________

Science Teacher’s Printed Name                      Signature                                              Date Signed

______________________________  ________________________________  _____________________

Parent or Guardian’s Printed Name                   Signature                                              Date Signed

STOP – Once the form is completed this far, send via FAX to the SRC (620-583-8222). After approval, the completed form will be returned (be sure to include return contact info below) for inclusion in the project.

Approved by Kansas State Science and Engineering Fair Scientific Review Committee (FAX to 620-583-8222):

________________________________  ____________________________________  _______________

SRC Chair’s Printed Name                                   Signature                                                     Date of Approval