2018 MSEF School Information & SRC/IRB Committee Form

This form Must be completed and returned by December 2, 2017. This form serves as an indication of your school's intent to participate in the 2018 Regional Fair.

Section I. Current School Information
School Name *
School District *
County *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of 2017 Key Teacher Name of 2017 Key Teacher * First Last
Key Teacher Email *
Alternative Email
School Phone Number School Phone Number * - ### - ### ####
School Fax Number School Fax Number - ### - ### ####
School Type *

School Type Public School Private School Home School Other Other
Section II.

List the members of your local SRC and IRB. The SRC should have at least a biomedical scientists (PhD, MD, DVM, or DO), a science educator, and one other member. The IRB should ave at least a science educator, school administrator, & either a psychologist, medical doctor, or registered nurse. Members can serve on both committees. HOWEVER, teachers may NOT sigh as the Chairperson.

ALL signatures required on Form 1B must be dated PRIOR to the beginning date of experimentation listed on From 1A. This is a MSEF/ISEF violation if not followed correctly and could result in a project disqualification.
Local SRC Chairperson Local SRC Chairperson * First Last
Degree(s) and/or Qualifications *
Employment Title: *
Employed by: *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Local IRB Chairperson Local IRB Chairperson First Last
Degree(s) and/or Qualifications
Employment Title:
Employed by:
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Other Local Committee Members. Email additional information if needed (region1msef@gmail.com) Other Local Committee Members. Email additional information if needed (region1msef@gmail.com) * First Last
Degree(s) and/or Qualifications *
Employment Title: *
Employed by: *
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Other Local Committee Members. Other Local Committee Members. * First Last
Degree(s) and/or Qualifications *
Employment Title: *
Employed by: *
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Other Local Committee Members. Other Local Committee Members. First Last
Degree(s) and/or Qualifications
Employment Title:
Employed by:
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

2018 MSEF School Information & SRC/IRB Committee Form

2018 MSEF School Information & SRC/IRB Committee Form

Section I. Current School Information

Section II.