Fillable LUCOM Research Volunteer (Liberty University)

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LUCOM Research Volunteer (Liberty University)

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  • 15 check-boxes
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CENTER FOR RESEARCH
VOLUNTEER FORM
Page 1 of 8
Center For Research
Volunteers Participating In Activities In Research Laboratories
Registration Form
CENTER FOR RESEARCH
VOLUNTEERS PARTICIPATING IN ACTIVITIES IN RESEARCH LABORATORIES
REGISTRATION FORM
• This form should be completed by and for all adult volunteers (i.e., persons 18 years
of age or older) who want to participate in activities in research laboratories, but who
are either not enrolled in a Liberty University regular catalog course or degree
program, or not employed by Liberty University.
• For volunteers who are less than 18 years of age; please complete the Registration
Form for Minors Participating in Research Activities.
IMPORTANT NOTES:
• All required sections of the form must be completed and submitted to the Liberty
University College of Osteopathic Medicine (“LUCOM”) Center for Research for
approval.
• The volunteer cannot participate in any research activities until all training
requirements are completed and written approval is received from the LUCOM
Center for Research.
• The responsible faculty member must make arrangement for the volunteer to
complete required training.
Instructions:
• Responsible faculty member:
o Complete Sections I, II, III, and IV
o Submit the completed document, sections I, II, III, IV, V-A, and V-B to LUCOM.
Send the completed document as a PDF to Barbra Lutz, Research
Manager of the Center for Research, at blutz1@liberty.edu. The
approved form will be returned to the sender and all cc’s.
• Volunteer:
o Complete Sections V-A and V-B and return to the responsible faculty member.
SECTION I: Demographic Information (to be completed by the responsible faculty
member)
R
ESPONSIBLE
F
ACULTY
M
EMBER
Responsible Faculty
Member Name & Title
Dept.
Campus Address
Room #
Alternate Contact Name
Phone #
Campus Address
Room #
V
OLUNTEER
I
NFORMATION
Name
Date of birth
Email
Campus Address (where
activities will take place)
Lab#
Phone #
Reason for Request
(Check One)
☐
Volunteering
☐
Internship
☐
Other:
Dates of Activity
From To
Page 2 of 8
Center For Research
Volunteers Participating In Activities In Research Laboratories
Registration Form
SECTION II: Experiment/Procedure Descriptions (to be completed by the responsible
faculty member)
Provide a non-technical abstract (using lay terminology) to describe the specific techniques
to be used by the volunteer. The description should include examples of the materials and
methods required (e.g., cell culture, PCR, cell sorting). If the volunteer will participate in
animal experiments, then include examples of the procedures (e.g., tail vein injection of
human cell lines; oral administration of chemotherapeutic agent). Attach a separate sheet, if
necessary.
Project Title (if applicable):
Project Description: This is a fillable box that will expand the text entered.
Page 3 of 8
Center For Research
Volunteers Participating In Activities In Research Laboratories
Registration Form
SECTION III: Requirements for Research involving Animals (to be completed by the
responsible faculty member)
As indicated below, the written approval of the LUCOM Center for Research will be required
prior to the volunteer beginning research activities.
The responsible faculty member agrees to sponsor and provide supervision
for___________________________________________ (insert the volunteer’s name), and by my signature
below I acknowledge and agree as follows:
• I have provided the volunteer’s hazard-specific training and had the volunteer
complete any other training required and provided by the LUCOM Center for
Research. I provided hazard-specific safety training by doing the following:
NOTE: The responsible faculty member must provide information to the volunteer
regarding specific lab hazards that will be encountered while participating in research
activities.
• Personal protective equipment appropriate for and specific to laboratory hazards will
be provided to the volunteer, and the volunteer will be instructed in the use/disposal
of this equipment.
• While in the laboratory, the volunteer will be supervised at all times by me or by
another responsible faculty member or full-time staff member to whom I have
specifically delegated the responsibility.
• Volunteers will not be issued card keys to any animal facilities.
• Volunteers must be continuously accompanied by responsible members of the
research team.
• My laboratory is in full compliance with all applicable LUCOM safety programs.
__________________________________________________________ ______________________________
Responsible Faculty Member Signature Date
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Page 4 of 8
Center For Research
Volunteers Participating In Activities In Research Laboratories
Registration Form
SECTION IV: Requirements for research involving hazardous chemicals or biological
materials:
The written approval of the LUCOM Center for Research will be required prior to the
volunteer beginning research activities. If the volunteer will participate in research involving
animals, then a LUCOM Center for Research approval is also required for that specific
function before beginning research activities. The following training courses must be
completed by the volunteer based on the type of research proposed.
Dates of Training completion (to be completed by the responsible faculty member)
Mandatory Additional Requirements (as necessary)
☐Orientation with Research Lab Safety
Training
(e.g., location of fire exits, use of protective equipment,
etc.)
Date of Completion:
☐CITI Training Modules under LUCOM Basic
Date of Completion:
☐Blood borne Pathogen Training
(if work involves the use of human cells, human cell lines,
human blood, human body fluids, or human blood borne
pathogens)
Date of Completion:
☐Additional CITI Training Modules on Research
Involving Vertebrate Animals
(if working with animals)
Date of Completion:
☐Additional CITI Training Modules on
Biochemical Research with Human Subjects
(if the volunteer has access to research subjects or data with
personal identifiers)
Date of Completion:
☐Radiation Safety Training
(if working with radioactive isotopes)
Date of Completion:
___________________________________________ __________________________________________________
Name of Responsible Faculty Member Department
Date
Page 5 of 8
Center For Research
Volunteers Participating In Activities In Research Laboratories
Registration Form
Section V: Volunteer Training Verification (to be completed by the Center for Research)
Mandatory Additional Requirements (as necessary)
☐Orientation with Research Lab Safety
Training
(e.g.,, location of fire exits, use of protective
equipment, etc.)
Date of Completion:
☐CITI Training Modules under LUCOM Basic
Date of Completion:
☐Blood borne Pathogen Training
(if work involves the use of human cells, human cell lines,
human blood, human body fluids, or human blood borne
pathogens)
Date of Completion:
☐Additional CITI Training Modules on Research
Involving Vertebrate Animals
(if working with animals)
Date of Completion:
☐Additional CITI Training Modules on
Biochemical Research with Human Subjects
(if the volunteer has access to research subjects or data with
personal identifiers)
Date of Completion:
☐Radiation Safety Training
(if working with radioactive isotopes)
Date of Completion:
Name (Center for Research Representative)
Signature (Center for Research Representative)
Date
SECTION VI: Volunteer Acknowledgement of Understanding
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signature
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Page 6 of 8
Center For Research
Volunteers Participating In Activities In Research Laboratories
Registration Form
A. By signing my name below, I acknowledge that:
• I have read the “Rules for Volunteers Performing Activities Working in
Laboratories” below.
• I UNDERSTAND these rules and AGREE to follow them.
• I UNDERSTAND that if I do not follow these rules, I may be asked to leave.
Volunteer Name:
Volunteer Signature: Date: ________________________
RULES FOR VOLUNTTEERS PERFORMING ACTIVITIES IN LABORATORIES
1. Never work alone in any laboratory environment or animal facility without direct,
immediate supervision from the responsible faculty member or someone designated
by him/her as supervisor. In the case of animal facilities, your supervisor must have
been issued a valid access key card.
2. Always follow the instructions of the responsible faculty member or designated
supervisor. Always report any accident (regardless of severity) immediately to the
responsible faculty member or designated supervisor.
3. Always wear the personal protective equipment as directed and dispose of it
appropriately. This personal protective equipment include safety glasses, gloves,
coats/gowns, and other face/body protection as dictated by the hazard with which
you are working.
4. Always keep your hands away from your face and wash them well with soap and
water prior to leaving any laboratory area.
5. Never eat, drink, chew gum, smoke, or apply lip balm or cosmetics while in any
laboratory environment.
6. Always wear closed-toe shoes while in any laboratory.
7. Always tie back long hair to keep it out of all hazards.
8. Always wear clothing that reduces the amount of exposed skin.
9. Always ask questions if you don’t understand the safety requirements.
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Page 7 of 8
Center For Research
Volunteers Participating In Activities In Research Laboratories
Registration Form
B. By signing this form, I certify that I:
• Understand that I am volunteering to participate in the Activity as described in
Section II above;
• Understand it is my choice to participate in this Activity, and that I am not being
required to do so;
• Understand that the Activity will take place in an academic laboratory at Liberty
University;
• Understand that there are certain hazards and risks involved in taking part in
activities in a laboratory including, but not limited to, cuts, scratches, eye injuries,
burns, and exposure to potentially harmful chemicals and biological matter and
agents that can cause illness and/or injury;
• Understand that there are certain hazards and risk involved in working with animals
including, but not limited to, scratches, bites, allergic reactions to animal dander, and
potential to contract disease from the animal;
• Understand that I am responsible for following all rules and instructions while
participating in the Activity and that my failure to do so will result in my participation
in the Activity ending;
• Understanding that if any time the LUCOM personnel in charge of the activity decide,
in their sole discretion, that it is in my best interest or the best interest of LUCOM for
me to no longer participate in the Activity, then my participation will immediately
end;
• Understand that by participating in this Activity, I will not be an employee of Liberty
University or a student enrolled in a Liberty University catalog course or degree
program; and
• Understand that Liberty University will not provide any accidental, health or other
insurance for me and that it is my responsibility to pay for treatment of any injuries
or illness that result from my participation in the Activity.
_____________________________________ __________________________________________ ______________________
Name of Volunteer Signature Date
Contact information for volunteer:
Home Phone: Work Phone:
Cell Phone: Email:
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signature
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Page 8 of 8
Center For Research
Volunteers Participating In Activities In Research Laboratories
Registration Form
Contact information for alternate person to contact in the event of emergency if
volunteer is incapacitated:
Name: Relation to volunteer:
Home Phone: Work Phone:
Cell Phone: Email:
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LUCOM Research Volunteer (Liberty University)

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Completed 18 July 2020

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