Qualified Scientist Form (2)

May be required for research involving human subjects, vertebrate animals, potentially hazardous biological agents, and DEA-controlled substances.  Must be completed and signed before the start of student experimentation.

Student’s Name________________________________________________________________

Title of Project_________________________________________________________________

To be completed by the Qualified Scientist:

Scientist Name:_________________________________________________________________

Educational Background:______________________________Degree(s):___________________

Experience/Training as relates to the student’s area of research:

______________________________________________________________________________

Position:___________________________________Institution:___________________________

Addresses:____________________________________Email/Phone:______________________

Have you reviewed the ISEF rules relevant to this project?                           Yes                         No

Will any of the following by used?                                                                Yes                         No

·  Human subjects                                                                      Yes                         No

·  Vertebrate animals                                                                  Yes                         No

·  Potentially hazardous biological agents (microorganisms,

      rDNA and tissues, including blood and blood products)        Yes                         No

· DEA-controlled substances                                                      Yes                         No

                  · Will you directly supervise the student?                                     Yes                         No

·  If no, who will directly supervise and serve as the Designated Supervisor?______

· Experience/Training of the Designated Supervisor:

Describe the safety precautions and training necessary for this project:

To be completed by the Qualified Scientist:                                 To be completed by the

I certify that I have reviewed and approved                                        Designated Supervisor when

the Research Plan prior to the start of the                                         the Qualified Scientist cannot

experimentation.  If the student or Designated                                     directly supervise.

Supervisor is not trained in the necessary                                            I certify that I have reviewed the

procedures, I will ensure her/his training.                                            Research Plan and have been

I will provide advice and supervision during                                        trained in the techniques to be used

the research. I have a working knowledge of                                      by this student, and I will provide

 the techniques to be used by the student in the                                   direct supervision.

Research Plan.   I understand that a

Designated Supervisor is required when the                                        _____________________________

student is not conducting experimentation                                           Designated Supervisor’s Printed Name

under my direct supervision.                                                              ___________________          __________

____________________________________                                   Signature                               Date of App.

Qualified Scientist’s Printed Name

                                                                                                        __________________           ____________________

____________________ ________________                               Phone                                      Email

Signature                             Date of Approval