Fill - Free fillable Minor Particpants In Laboratory Request For Approval (Saint Louis University) PDF form

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

First 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

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: _______________________________

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