Fill - Free fillable Minor In Laboratories Parent Guardian Consent Form (Saint Louis University) PDF form

FORM B [Policy on Minors in Laboratories: FORM B Version 2016-05-09] Page 1 of 4

[It is the responsibility of the Sponsoring Faculty Member/Researcher to obtain the appropriate signatures and to return the

signed form to the Office of Environmental Health and Safety, Caroline Building, Suite C305.]

Parent/Guardian Consent for a Minor in Laboratories

Participating Minor (hereinafter referred to as “participant”):

Name: _________________________________________, ________________________________

(Last Name) (First Name)

Age: ________ Date of Birth: ______________________ Gender:  Female  Male

(Mo/Day/Yr)

Address: ____________________________________________________________________________

(Street Address)

______________________________________________________ ___________________

(City, State, and Zip Code) (Telephone No.)

I, the undersigned Parent/Guardian of the above referenced participant, acknowledge that I understand

and herby consent and agree as stated below.

The named participant may observe or participate in laboratory and/or field study activities at Saint Louis

University (SLU) under the direction of:

_______________________________________ _______________________________________

(Sponsoring Faculty Member/Researcher) (Department)

_______________________________________ _______________________________________

(Other Designated Lab Supervisor of Minor – If applicable) (Department)

_______________________________________ _______________________________________

(Other Designated Lab Supervisor of Minor – If applicable) (Department)

Campus locations/addresses at which activities will take place [Include building name(s) and room

number(s)]:

_______________________________________________________________________

Start Date: _____________________ Daily Start Time: _____________

(Mo/Day/Yr)

End Date: _____________________ Daily End Time: _____________

(Mo/Day/Yr)

Reason for Request:  STARS Program  Science Fair  Scouts

 Internship 

Special Tour  Volunteering

 Other (specify): ________________________________________________________________

Project Title: ________________________________________________________________________

_________________________________________________________________________________

FORM B [Policy on Minors in Laboratories: FORM B Version 2016-05-09] Page 2 of 4

[It is the responsibility of the Sponsoring Faculty Member/Researcher to obtain the appropriate signatures and to return the

signed form to the Office of Environmental Health and Safety, Caroline Building, Suite C305.]

Description of Project:  See text box below.  See additional page(s) attached.

_________________________________________________________________________________

Role of the minor(s) in project:  See text box below.  See additional page(s) attached.

_________________________________________________________________________________

______________________________________________________________

_________________________________________________________________________________

FORM B [Policy on Minors in Laboratories: FORM B Version 2016-05-09] Page 3 of 4

[It is the responsibility of the Sponsoring Faculty Member/Researcher to obtain the appropriate signatures and to return the

signed form to the Office of Environmental Health and Safety, Caroline Building, Suite C305.]

Some laboratory facilities at SLU or field study locations are potentially hazardous environments. Even

under ideal conditions, including the proper use of materials and adherence to safety procedures, a risk of

personal injury exists. The attached Potential Hazard Information Table provides the most common

potential hazards, but it is not intended to be an exhaustive list. Failure to adhere to established

procedures may result in even greater risk. The participant will receive appropriate training concerning

how to identify hazards and how to work safely with materials, equipment, and animals (if applicable)

and will be supervised in the handling of instrumentation, materials, and animals that may pose a risk. I

understand that the participant may be removed from the project on a temporary or permanent basis if he

or she refuses or is unable to follow safety rules, wear assigned personal protective equipment, or perform

activities as directed.

Prior to participation, I agree to notify the above named faculty member/researcher or supervisor of any

allergies or other physical, mental, or emotional condition that might limit the participant’s ability to

safely participate in activities in the laboratory.

I give permission to Saint Louis University, its physicians, faculty and staff members, agents, and

services to provide such emergency care and treatment to the minor participant as in their judgment may

be deemed necessary or may be advisable in the event that the minor should require emergency care while

participating in the project at SLU. I agree to assume the costs of such emergency care and treatment if

any such costs are incurred.

In consideration of the opportunity of the above named minor to observe or participate in these activities,

I agree to indemnify, release, defend, and hold harmless the Board of Trustees of Saint Louis University,

Saint Louis University, its administration, faculty, staff and agents from any and all claims, suits, and

damages relating to, or arising out of, the minor’s participation in the project, excepting only claims, suits,

and damages arising out of the sole negligence of the University.

Signature of Parent/Guardian: ___________________________________ Date: ______________

(Mo/Day/Yr)

Printed Name of Parent/Guardian: ____________________________________________________

Daytime Phone of Parent/Guardian: _____________________ Cell Phone: ___________________

Emergency Contact (other than parent): _________________________________________________

Emergency Contact Daytime Phone: _____________________ Cell Phone: __________________

Witness Signature: ___________________________________________ Date: ______________

(Mo/Day/Yr)

Printed Name of Witness: _____________________________________

Minor Participant Agreement: I, the undersigned minor Participant, agree to follow the safety rules

and procedures reviewed with me by my Sponsoring Faculty Member/Researcher, the Designated

Supervisor and any other Saint Louis University faculty or staff member. I agree to wear at all times

necessary the personnel protective equipment prescribed for me by any of these individuals as required

for my safety. I will not engage in any rough, boisterous, or rowdy play (“horseplay”) at any time during

my visit. I will be attentive to all instruction from my sponsoring Faculty Member/Researcher and the

Designated Supervisor.

Signature of Minor Participant: ___________________________________ Date: ______________

(Mo/Day/Yr)

Printed Name of Minor Participant: ____________________________________________________

TABLE B [Policy on Minors in Laboratories: TABLE B Version 2016-05-09] Page 4 of 4

Potential Hazard Information Table*

[*This table is to be used as a reference for the form: Parent/Guardian Consent for a Minor in Laboratories]

[Version 2016-05-08]

Potential Hazards

General Information

Example

Animal

Research animals represent a variety of species, temperaments, and health conditions. They can cause physical injuries,

transmit zoonotic diseases (diseases passed from animals to humans); or be a source of allergens or toxins.

Scratch, bite (physical injury)

Rabies, toxoplasmosis (zoonotic disease)

Chemicals

A chemical is a refined compound that may be in the form of a solid, liquid, or gas. Potential injuries include burns of the skin

or eyes, respiratory problems; allergic reactions; irritation of skin, eyes, and mucous membranes; and illness. Based on their

specific effect, chemicals may be classified in one or more of these categories:

• Allergens – cause of allergic reactions

• Carcinogens – produce cancer

• Teratogen – affect male and female reproductive systems; may cause birth defects in the developing fetus.

• Flammables – burn or explode

• Reactives – react explosively

• Corrosives – cause tissue damage upon contact including inhalation

• Toxins – cause illness or death upon exposure. (Neurotoxins specifically affect the nervous system).

Benzene (carcinogen)

Thalidomide (teratogen)

Acetone, xylene, alcohol (flammables)

Peroxides, acrylamide (reactives)

Acids, bases (corrosives)

Cyanide (toxin)

Equipment and

Instrumentation

Potential hazards from mechanical or electrical equipment include loud noises, very high or very low temperatures, electrical

shock, pinching/crushing injuries.

Autoclaves/sterilizers (burns)

Gases

Gases may be toxic, corrosive, or flammable. They may cause eye and skin irritations, respiratory problems, light-headedness,

asphyxiation, and fainting.

Some gases are stored in metal cylinders under high pressure. Compressed gas cylinders can explode causing injury from

high speed projectiles.

Nitrogen, helium, any other non-oxygen gas

(asphyxiant)

Hydrogen (flammable)

Ammonia (toxic)

Lasers

Light of a single color emitted in a narrow beam. Hazards from lasers are classified as:

• Class 1 - No hazard.

• Class 1M – No hazard unless the beam is viewed with an optical instrument (e.g. eye-loupe or telescope).

• Class 2 – Insufficient power to cause eye damage within the normal aversion response time.

• Class 2M – Insufficient power to cause eye damage with the normal aversion response and beam is viewed with an

optical instrument (e.g. eye-loupe or telescope).

• Class 3R – Some direct and indirect viewing (specular reflection) can cause eye injury, does not pose a fire hazard or

diffuse viewing hazard.

• Class 3B – Direct and indirect viewing (specular reflection) of the beam can cause eye injury.

• Class 4 – Direct and indirect (specular and diffuse reflection) viewing of the beam can cause eye injury. Can cause skin

injury, is a potential fire hazard, may produce hazardous laser generated air contaminants and plasma radiation.

Nitrogen lasers (Class 3B)

Examples of Class 4 lasers used:

• Ophthalmology

• Surgery

Microbiological

Agents

Living organisms such as viruses, bacteria, fungi, prions, and parasites. Those that are capable of causing disease are called

pathogens. The effects of these agents are organism dependent and can range from mild, treatable to severe, to untreatable.

Hazards from microbiological agents are classified as:

• Biological Safety Level 1 – No hazard to healthy adults

• Biological Safety Level 2 – Cause mild to severe illness

• Biological Safety Level 3 – Cause severe illness and possible death

• Biological Safety Level 4 – Not allowed at SLU.

Bakers Yeast, E. Coli K12 (Level 1)

Adenovirus, Influenza, Salmonella, HIV

(Level 2)

Mycobacterium tuberculosis, SARS virus,

(Level 3)

Radiation/Radioactive

Materials

High energy particles (alpha & beta) or waves (X-rays and gamma rays). Unprotected exposure can cause skin or eye

damage, cellular damage, and long-term health problems.

Uranium, Phosphorous 32, Iodine 125

X-rays

Recombinant

Materials

DNA that has been genetically engineered (altered) by combining it with DNA from another source. Viruses may be used as

vectors to infect (transfect) cells with the foreign DNA.

A transgenic organism is one that has had genes from another organism inserted into its genes. The consequences of

introducing such foreign genes into human body may be difficult to predict.

Adenovirus, adeno-associated virus

(viral vector)

Toxins (Biological)

Poisons produced by microbiological organisms, plants, or animals. These agents can cause tissue and organ damage or death.

Ricin (plant), Snake venom (animal),

Botulinum neurotoxin (bacteria)

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