Student Safety and Ethics Assessment Form 1.0
Student's Name ___________________________________________
Title of Project ___________________________________________
Review and complete the following:
1) I have completed the "Project Proposal Form" and my Adult Supervisor and I have both signed the "Project Proposal Form 1.1")
2) Complete the "Adult Supervisor Form 1.2" if the project is to be done outside school
3) This project involves the following area(s) and requires Scientific Review Committee and/or a "Qualified Professional form 1.3".
Humans (requires prior SRC approval and forms for Human Subjects form 4A and form1.3 )
Nonhuman Vertebrate Animals (requires prior SRC approval and forms for Animals form and form1.3 )
Recombinant DNA (requires prior SRC approval and form1.3 )
Pathogens (requires prior SRC approval and form1.3 )
Controlled Substances (requires prior SRC approval and form1.3 )
Human/Animal Tissue (requires SRC approval and Tissue form and form1.3 )
or Devices (
requires a qualified professional supervisor form1.3
If a project involves human subjects, the student must obtained approval from an SRC Scientific Review Committee
Nonhuman Vertebrate Animals, Pathogenic Agents, Controlled Substances, Recombinant DNA, Human/Animals Tissue
If a project involves nonhuman vertebrate animals, pathogenic agents, controlled substances, recombinant DNA, or human/animal tissue, the student must have regional fair Scientific Review Committee (SRC) approval before experimentation is started.
Hazardous substances or devices require review and proper supervision [Qualified Professional Form]
Chemicals (i.e., hazardous, flammable, explosive or highly toxic; carcinogens; mutagens, all pesticides). I have reviewed with the student the Material Safety Data Sheet (MSDS) Listing for each chemical that will be used. I have also reviewed the proper safety standards for each chemical including toxicity data, proper handling techniques, and disposal methods. Available in all High School chemistry Labs.
Equipment (i.e., welders; lasers; voltage greater than 220 volts). I have reviewed with the student the proper operational procedures and safety precautions for the equipment to be used by the student. For information about laser standards and research, write ------
Firearms. I have reviewed with the student the proper safety standards for firearms use. I have seen a valid FAC for the possession of a firearm. For homemade projectile launchers I have reviewed with local law enforcement authorities the specific use of the device in the research plan.
Radioactive Substances. I have reviewed the proper safety standards for each radioactive substance the student will use.
Radiation (i.e., x-ray or nuclear; unshielded ionising radiation of 100400 nm wavelength). I have reviewed with the student the proper safety methods concerning the type of radiation the student will use.
Adult Supervisor (Print) (Sign) Date
NOTE: This page should be part of the student's papers.