Human or Animal Tissue Form

Grades 4-8

 

Required for all projects using human or animal tissues, including living cells or tissue (body) fluids.

 

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 (use a separate page if necessary):

1. What tissue(s), organ(s), or part(s) will be used?

2. Where will the above tissue, organ, or part be obtained? Identify each separately and provide contact

information for research institutions, hospitals, dentists, veterinary clinics or other non-commercial business.

3. Briefly describe how the tissue(s) will be used in the experiment.

4. Identify the method of tissue disposal upon completion of the experiment

To be completed by Science Teacher or Mentor that supervises the student (mark all appropriate boxes):

_ I verify that the student will work solely with tissues supplied by myself or other qualified personnel; students

will not collect any tissues themselves.

   I certify that if vertebrate animals were euthanized (killed), it was not solely for this experiment; specific

information detailing the reason for euthanasia is included in the second answer above.

   I certify that any blood, blood products, fresh tissues, or body fluids used in this project will be handled in

accordance with the standards and guidance set forth in Occupational Safety and Health Act, 29CFR

1910.1030 – Blood Borne Pathogens (available on-line at http://www.osha.gov/SLRC/bloodbornepathogens/standards.html).

______________________________ ______________________________ ____________________

Printed Name Signature Date Signed

(Must be prior to experimentation)

____________________________________________________ ____________________

Title (and Institution) Phone

STOP – Once the form is completed this far, send via FAX to the SRC (816-501-4802). After approval, the

completed form will be returned (be sure to include return contact information below) for inclusion in the project.

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

 

__________________________________                 _______________________________                        _____________

KSSEFRC Chair’s Printed Name                         Signature                                                          Date of Approval