INLAND SCIENCE AND ENGINEERING FAIR

CERTIFICATION OF TISSUE SAMPLE SOURCE

 

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.

 

RESEARCH PLAN

           

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: _____________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

 

 

 

 

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INLAND SCIENCE AND ENGINEERING FAIR
CERTIFICATIOIN OF TISSUE SAMPLE

PAGE TWO

 

 

 

4.                  List objectives of the experiment and describe fully the methods and techniques involved:

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Student ___________________________________ Date____________

 

 

CERTIFICATION

 

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 ___________

 

 

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