Human Subjects Form 2 (4-8)

Grades 4-8

Required for all research involving humans (including student researcher).

NOTE: All signatures on this form (including participants) must be obtained before experiment begins.

**All completed consent forms must be included with the Fair application form that is sent to the Kansas State Science and Engineering Fair.**

Student's Name _____________________________________________________________________________

Title of Project ______________________________________________________________________________

Three questions to be completed by Student Researcher (on an attached page) and shared with the

Institutional Review Board (IRB) before their review of the project (see next box):

1. Describe the purpose of this study and list all procedures (including duration) in which human subjects will be

involved. Attach any surveys or questionnaires to be used.

2. Describe and assess any potential risks, discomfort, and potential benefits (physical, psychological, social,

legal, or other) that may be reasonably expected with participation in this research.

3. Describe procedures used to minimize risk, obtain informed consent, and maintain confidentiality.

All IRB Signatures Required Prior to Start of Research Project; signatures signify approval of project.

NOTE: If a Medical Professional (other than a parent) is not available to this student, contact the Science Pioneers office.

______________________________ ______________________________ ____________________

Medical Professional's Printed Name Signature Date of Approval

Medical Professional must be a psychologist, psychiatrist, medical or osteopathic doctor, licensed social worker, licensed clinical professional

counselor, physician’s assistant, or registered nurse – circle the appropriate description – and cannot be parent or guardian of the student.

______________________________ ______________________________ ____________________

 Educator's Printed Name Signature Date of Approval

______________________________ ______________________________ ____________________

School Administrator's Printed Name Signature Date of Approval

STOP – Once the original form is completed this far, copy the completed form (with the three questions and answers copied on the back or attached) as the consent form for potential participants (see below).

To be completed by each human subject (including the student researcher) prior to experimentation (using copies of original signed (approved) form):

__ I am 18 years of age or older. (If not, the signature of a parent/guardian is also required.)

__ I have read and understand the conditions of this study, and I consent to participate in this research

procedure. I realize I am free to withdraw my consent and to withdraw from this activity at any time.

__ I consent to the use of visual images (photos, videos, etc.) involving my participation in this research.

________________________________ _________________________________ ________________

Participant's Printed Name Signature Date Signed

If participant is under 18 years old, a parent/guardian signature is required.

_ I have reviewed the conditions of this study (including any tests, surveys or questionnaires to be used) and allow participation in this project.

______________________________ __________________________________ ________________

Parent/Guardian's Printed Name Signature Date Signed