Fillable Form A-request For Approval Of Research Project Involving Minor Participants In Laboratories (Saint Louis University)

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Form A-request For Approval Of Research Project Involving Minor Participants In Laboratories (Saint Louis University)

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FORM A [Policy on Minors in Laboratories: FORM A Version 2016-05-09] Page 1 of 5
REQUEST FOR APPROVAL OF RESEARCH PROJECT INVOLVING
MINOR PARTICIPANTS IN LABORATORIES
Minors in Laboratories Request Number:
INSTRUCTIONS TO SPONSORING FACULTY MEMBER/RESEARCHER
1. Prior to submission of this form, contact the Office of Environmental Health and Safety to discuss the
request with the Director, or his designee, and to obtain a “Minors in Laboratories Request Number”.
(STARS Mentors are exempted from this requirement and a request number will be assigned after
submission.)
2. Complete all pages of this form, and execution of the Sponsoring Faculty Member/Researcher
Acknowledgement on the last page.
3. Forward the completed request, inclusive of all executed Parent/Guardian Consents, at least two
weeks in advance of the proposed start date, either by:
(a) Interoffice mail to the Office of Environmental Health and Safety, Caroline Building, Suite 305,
or
(b) Email, with a PDF scan of the executed forms attached, to: envsafety@slu.edu
Applicant:
_______________________________________ ____ _______________________________________
(Sponsoring Faculty Member/Researcher) (Department)
_______________________________________ ____ _______________________________________
(Other Designated Lab Supervisor of Minor(s) – If applicable) (Department)
_______________________________________ ____ _______________________________________
(Other Designated Lab Supervisor of Minor(s) – If applicable) (Department)
Lab Locations: Campus locations/addresses at which activities will take place [Include building name(s)
and room number(s)]:
_________________________________________________________________________________
_________________________________________________________________________________
Start Date of Minor(s): Daily Start Time: _____________
(Mo/Day/Yr)
End Date of Minor(s): __________________ Daily End Time: _____________
(Mo/Day/Yr)
Reason for Request: STARS Program Science Fair Scouts
Internship Special Tour Volunteering
Other (specify): ________________________________________________________________
FORM A [Policy on Minors in Laboratories: FORM A Version 2016-05-09] Page 2 of 5
Project Title: _______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Description of Project: See text box below. See additional page(s) attached.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Chemical Use? No
Yes; hazardous chemicals are used, see text box below. See additional page(s) attached.
(1) ________________________________________________________________________
(2) ________________________________________________________________________
(3) ________________________________________________________________________
(4) ________________________________________________________________________
(5) ________________________________________________________________________
(6) ________________________________________________________________________
(7) ________________________________________________________________________
(8) ________________________________________________________________________
FORM A [Policy on Minors in Laboratories: FORM A Version 2016-05-09] Page 3 of 5
Animal Use? No
Yes; if yes, answer the following questions:
(a) Will the minor participant be working with live animals?
Yes No
(b) If yes to (a), specify applicable IACUC protocol number(s): _________________________
(c) Will the minor participant need access to the animal facility?
Yes No
(d) Will the minor participant be handling animal products or dead animals?
Yes No
Biological Materials Use? No
Yes; but not a known or potentially hazardous biological material.
(a) If yes, please list or provide a description of the biological materials that the minor participant
will be working with:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Yes; a known or potentially hazardous biological material but used for teaching purposes only.
(This includes work with attenuated strains of microbial pathogens and human-derived
materials.)
(a) If yes, please list or provide a description of the biological material the minor participant will
be working with:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
(b) If human-derived materials human derived materials, please confirm that OSHA required
Bloodborne Pathogen (BBP) training has been completed for each Saint Louis University
employee by providing their names, titles and the training date(s) in the table below.
Name Title
Date Completed
BBP Training
Note: Minor participants will also be required to complete BBP training prior to working
with human derived materials.
Yes; a known or potentially hazardous biological material, or recombinant nucleic acid
biological material, used in research.
(a) If yes, specify applicable IBC protocol number(s): ________________________________
(b) If yes, has an amendment adding the student(s) to each IBC protocol been made?
Yes (a copy is included with this application)
No (approval of this request for approval of research project involving minors in
laboratories will be delayed or denied)
FORM A [Policy on Minors in Laboratories: FORM A Version 2016-05-09] Page 4 of 5
Role of the minor(s) in project: See text box below. See additional page(s) attached.
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
List Minor Participant(s):
Last Name
Age
Parent/Guardian
Consent Attached
Yes No
Yes
No
Yes No
Yes No
Yes
No
Yes No
Yes
No
Yes No
Yes No
Yes
No
Yes No
Yes
No
Yes
No
Yes No
Yes
No
FORM A [Policy on Minors in Laboratories: FORM A Version 2016-05-09] Page 5 of 5
REQUEST FOR APPROVAL OF RESEARCH PROJECT INVOLVING
MINOR PARTICIPANTS IN LABORATORIES
Minors in Laboratories Request Number*:
(See Page 1)
Saint Louis University Sponsoring Faculty Member/Researcher Acknowledgement of Policy
on Minors in Laboratories:
I, _______________________________________________ , certify that I have read and
(Typed or printed name of sponsoring faculty member/researcher)
understand the Saint Louis University Policy on Minors in Laboratories and agree to fully comply
with all of the requirements outlined.
Sponsoring Faculty Member/Researcher: ____________________________________________
(Signature*)
Date: ____________________ Campus Phone Number: _________________________
(Mo/Day/Yr)
* Signature: Completed forms may be submitted without signature if emailed from the applicant’s SLU Email
address which shall be taken to be equivalent to the applicant’s signature for the review phase, in order to
expedite submission. A signed copy of this page must be submitted to the Office of Environmental Health
and Safety by interoffice mail, fax or email (as PDF attachment) before final approval can be granted.
Saint Louis University Office of Environmental Health and Safety Use Only
OEHS Review
Area:
BSO
CHO
ARSO
DIR
Initials:
Date:
/ /
/ /
/ /
/ /
Saint Louis University Office of Environmental Health and Safety Use Only
APPROVAL
Minors In Laboratories Approved Project No.:
Approved by:
__________________________________________
(Signature)
Date of Approval:
_____________________
(Mo/Day/Yr)
Printed Name: Mark G. Haenchen, M.S., J.D.
Title: Director, Office of Environmental Health and Safety
Copies to (as checked):
Sponsoring Faculty Member
Researcher’s Department Chairperson
Department Business Manager
Vice President for Research
Dean
Building Manager – if applicable
Other: _______________________________
Other: _______________________________
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Form A-request For Approval Of Research Project Involving Minor Participants In Laboratories (Saint Louis University)

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Completed 19 July 2020

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