Qualified Professional Supervisor Form 1.3

download form 1.3


Student's Name ___________________________________________

Title of Project ___________________________________________


To be completed by Qualified Professional (Please Print)


Name ___________________________________________

Position ___________________________________________

Address ___________________________________________

Phone (w) ________________ (h) ________________


1) Will non-human vertebrate animals be used? Yes No

2) Will human subjects be used? Yes No

3) Will controlled substances be used? --------------------------- Yes No

Will they be used according to government regulations? ------ Yes No

Please list the name(s) of the substance(s) __________________________________

4) Will pathogenic substances be used? --------------------------- Yes No

(Any bacterium or fungi isolated from their natural habitat will be considered pathogenic)

If yes will accepted procedures be used? ------------------------- Yes No

7) Will human blood blood products or bodily fluids be used? -------- Yes No



I have reviewed the research proposal and am qualified in the techniques required by this student. I have the necessary qualifications prior to the start of experimentation. And will take direct responsibility for any safety and ethics concerns for this project in that I will provide direct supervision.




Qualified Professional Supervisor (Print) (Sign) Date