INLAND SCIENCE AND
ENGINEERING FAIR
Name of Student
__________________________________________________
Project Title
______________________________________________________
This form must be completed
for all projects using tissue(s), organ(s), human part(s), or animal parts,
including blood.
When live or preserved
tissue samples or parts of human or vertebrate animals are obtained by the
student from an institution or biomedical scientist, a statement signed by the adult
providing the tissue is required. Students may NOT be involved in the direct
acquisition of these samples from living human or other vertebrate animals.
Live tissue samples must be:
a) from a continuously maintained tissue culture line already available to institutional researchers, OR
b)
from animals already being used in an on-going institutional research project.
1.
Tissue(s), organ(s), or
part(s) used:
_____________________________
_____________________________
_____________________________
Tissue
sample is from:
______Human
source
______Vertebrate
animal source
Genus,
species and common name ___________________________________
________________________________________________________________
2.
Starting Date:
_________________________________________________
3.
Purpose of project:
_____________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Page 1 of 2
INLAND SCIENCE AND ENGINEERING
FAIR
CERTIFICATIOIN OF TISSUE SAMPLE
4.
List objectives of the
experiment and describe fully the methods and techniques involved:
Signature of Student
___________________________________ Date____________
Institution or company that
is source of Tissue Sample:
Name
________________________________________________________________
Address
_______________________________________________________________
______________________________________________________________________
I certify that the above
listed materials were provided by me or my institution and that the student
listed was NOT involved in the direct acquisition of the samples provided or purchased.
Signature____________________________ Title
______________________
Date ________________________________
Telephone
Number ___________
Page 2 of 2