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:
______Vertebrate animal source
Genus, species and common name ___________________________________
2. Starting Date: _________________________________________________
3. Purpose of project: _____________________________________________
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INLAND SCIENCE AND ENGINEERING
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:
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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