GRADES 4-6 G.W.CARVER SCIENCE FAIR APPLICATION COMPLETED BY STUDENT AND SPONSOR. ALL INFORMATION MUST BE TYPED OR NEATLY PRINTED.

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1 GRADES 4-6 G.W.CARVER SCIENCE FAIR APPLICATION COMPLETED BY STUDENT AND SPONSOR. ALL INFORMATION MUST BE TYPED OR NEATLY PRINTED. APPLICATIONS MUST BE RECEIVED BY 5 PM ON MONDAY, JANUARY 9, Student Last Name: First Name: 2. Home Address: 3. City: State: PA Zip: 4. Home Phone: 5. Grade: 6. Gender: Age: 7. Student s Address: 8. School Name: Pony #: 9. School Address: 10. City: State: PA Zip: 11. School Phone: School Fax: 12. Sponsor Last Name: First Name: 13. Sponsor Address: 14. Title of Project: 15. Category Number: (select a number from 1-5 using the list below) 16. Does your project require electricity? Yes No 17. Are you bringing a computer? Yes No CATEGORIES: Schools can send 3 projects per category, per school, except categories 4 & 5*. SELECT ONE CATEGORY (Selection MUST be the same as #15). 1. Life Science 2. Earth Science 3.Physical Science *4. Team Projects (1 team of 2-3 students per school) *5. Consumer Science (1 project per school) ***MUST HAVE ALL SIGNATURES*** STUDENT S Signature Date: SPONSOR S Signature Date: PARENT S Signature Date: By signing this form all parties understand and agree that photopgraphs, videos, and names may be used for media and print material. ALL OTHER REQUIRED SCIENCE FAIR FORMS VISIT and take the Special Forms Quiz

2 Student s Name(s): Project Title: 1. I have reviewed the Intel ISEF Rules and Guidelines. 2. I have reviewed the student s completed Student Checklist (1A) and Research Plan. 3. I have worked with the student and we have discussed the possible risks involved in the project. 4. The project involves one or more of the following and requires prior approval by an SRC, IRB, IACUC or IBC: Humans Potentially Hazardous Biological Agents Vertebrate Animals Microorganisms rdna Tissues 5. Items to be completed for ALL PROJECTS Adult Sponsor Checklist (1) Research Plan Student Checklist (1A) Approval Form (1B) Regulated Research Institutional/Industrial Setting Form (1C) (when applicable after completed experiment) Continuation/Research Progression Form (7) (when applicable) 6. (check all that apply): (Requires prior approval by an Institutional Review Board (IRB); see full text of the rules.) Human Participants Form (4) or appropriate Institutional IRB documentation Sample of Informed Consent Form (when applicable and/or required by the IRB) (Requires prior approval, see full text of the rules.) required.) Vertebrate Animal Form (5B) for projects conducted at a Regulated Research Institution. (Institutional Animal Care and Use Committee (IACUC) approval required prior experimentation.) applicable) (Requires prior approval by SRC, IACUC or Institutional Biosafety Committee (IBC), see full text of the rules.) Potentially Hazardous Biological Agents Risk Assessment Form (6A) Human and Vertebrate Animal Tissue Form (6B) to be completed in addition to Form 6A when project (No prior approval required, see full text of the rules.) Risk Assessment Form (3) Note: The following are exempt from prior review but require a risk assessment: projects involving protists, archae and similar microorganisms, for projects using manure for composting, fuel production or other non-culturing experiments, for projects using color change coliform water test kits, microbial fuel cells, and for projects involving decomposing vertebrate organisms. Adult Sponsor s Printed Name Signature Date of Review Phone Page 28 International Rules: Guidelines for Science and Engineering Fairs , student.societyforscience.org/intel-isef

3 1. a. Student/Team Leader: Grade: Phone: b. Team Member: c. Team Member: 2. Title of Project: 3. School: School Phone: School Address: 4. Adult Sponsor: Phone/ 5. Does this project need pre-approval? Yes No Tentative start date: 6. Is this a continuation/progression from a previous year? Yes No If Yes: a. Attach the previous year s Abstract and Research Plan Continuation/Research Progression Form (7) 7. This year s laboratory experiment/data collection: Actual Start Date: (mm/dd/yy) End Date: (mm/dd/yy) 8. Where will you conduct your experimentation? (check all that apply) Research Institution School Field Home Other: 9. List name and address of all non-school work site(s): Name: Address: Phone: International Rules: Guidelines for Science and Engineering Fairs , student.societyforscience.org/intel-isef Page 29

4 1. The Research Plan is a succinct detailing of the rationale, research question(s), methodology, and risk assessment of your research project and should be completed before experimentation. For all projects requiring preapproval, this document must be reviewed and approved by the appropriate approval committee (e.g. IRB, IACUC, SRC) before experimentation. ALL changes made to the original plan be completed either pre- or post-experimentation. 2. All projects should complete a Post Project Summary after experimentation. The Research Plan and Post Project Summary should include the following:: a. What is the RATIONALE for your project? Include a brief synopsis of the background that supports your research problem and b. State your. How is this based on the rationale described above? c. Describe the following in detail: Procedures: Detail all procedures and experimental design including methods for data collection. Describe only your project. Do not include work done by mentor or others. Identify any potential risks and safety precautions needed. Describe the procedures you will use to analyze the data/results that answer research questions or hypotheses. Discuss the data/results and the conclusions that can be drawn. d. Bibliography: you plan to use vertebrate animals, one of these references must be an animal care reference. applicable. 1. Participants. Describe who will participate in your study (age range, gender, racial/ethnic composition). Identify any vulnerable populations (minors, pregnant women, prisoners, mentally disabled or economically disadvantaged). Methods. What will participants be asked to do? Will you use any surveys, questionnaires or tests? What is the frequency and length of time involved for each subject? Risk Assessment Risks. What are the risks or potential discomforts (physical, psychological, time involved, social, legal, etc.) to participants? How will you minimize the risks? the data? What will you do with the data at the end of the study? Describe how you will inform participants about the purpose of the study, what they will be asked to do, that their participation is voluntary and they have the right to stop at any time. ALTERNATIVES Explain potential impact or contribution this research may have Detail all procedures to be used Include methods used to minimize potential discomfort, distress, pain and injury to the animals during the course of experimentation Detailed chemical concentrations and drug dosages Detail animal numbers, species, strain, sex, age, source, etc. Describe housing and oversight of daily care Discuss disposition of the animals at the termination of the study 3. Potentially hazardous biological agents research: Describe Biosafety Level Assessment process and resultant BSL determination Detail safety precautions Discuss methods of disposal Describe Risk Assessment process and results Detail chemical concentrations and drug dosages Describe safety precautions and procedures to minimize risk Discuss methods of disposal Page 30 International Rules: Guidelines for Science and Engineering Fairs , student.societyforscience.org/intel-isef

5 A completed form is required for each student, including all team members. 1. I understand the risks and possible dangers to me of the proposed research plan. I have read the Intel ISEF Rules and Guidelines and will adhere to all International Rules when conducting this research. I have read and will abide by the following Ethics statement Student s Printed Name Signature Date Acknowledged (mm/dd/yy) (Must be prior to experimentation.) I have read and understand the risks and possible dangers involved in the Research Plan. I consent to my child participating in this research. Parent/Guardian s Printed Name Signature Date Acknowledged (mm/dd/yy) (Must be prior to experimentation.) 2. (Required for projects requiring prior SRC/IRB APPROVAL. Sign 2a or 2b as appropriate.) a. Required for projects that need prior SRC/IRB (humans, vertebrates or potentially hazardous biological agents). The SRC/IRB has carefully studied this project s Research Plan and all the required forms are included. My signature indicates approval of the Research Plan before the student begins experimentation. SRC/IRB Chair s Printed Name OR b. Required for research conducted at all Regulated. This project was conducted at a regulated research institution ( ), was reviewed and approved by the proper institutional board before experimentation and complies with the Intel ISEF Rules. Attach (1C) and required institutional SRC Chair s Printed Name Signature Date of Approval (mm/dd/yy) (Must be prior to experimentation.) Signature 3. Date of Approval (mm/dd/yy) I certify that this project adheres to the approved Research Plan and complies with all Intel ISEF Rules. Regional SRC Chair s Printed Name Signature Date of Approval State/National SRC Chair s Printed Name Signature Date of Approval International Rules: Guidelines for Science and Engineering Fairs , student.societyforscience.org/intel-isef Page 31

6 Almost Finished! Remember to complete the extra form quiz online at Building your Project at Complete all additional forms that align with your project! Finalize and submit your application by following the 4 steps below: Submit Your Application 1. Register online through the Register Link in Building your Project at 2. Teachers must include the Elementary or Secondary Student Approval List with their student applications. 3. Full applications (including the proposal and additional forms) should be delivered or mailed to: Rachel Cherry School District of Philadelphia Education Center 440 N. Broad Street, Suite 251 Philadelphia, PA science@philasd.org 4. Applications must be received no later than 5:00 PM on Monday, January 9 th, 2017

GRADES 4-6 G.W.CARVER SCIENCE FAIR APPLICATION COMPLETED BY STUDENT AND SPONSOR. ALL INFORMATION MUST BE TYPED OR NEATLY PRINTED.

GRADES 4-6 G.W.CARVER SCIENCE FAIR APPLICATION COMPLETED BY STUDENT AND SPONSOR. ALL INFORMATION MUST BE TYPED OR NEATLY PRINTED. APPLICATIONS MUST BE RECEIVED BY 5 PM ON MONDAY, JANUARY 11, 2016 1. Student