Minors Research Proposal

# M

Principal Investigator/Sponsor: Department:

Address/Box: Phone: Email:

Student/Minor Name: Date of birth: School:

This project is(check one):

Science Fair Project Volunteering

Employment Other

If Part of a NAU Sponsored Program, which program?

Other (explain)

This work will be performed in: Bldg , Room(s)

Project Title:

Materials and Equipment to be Used - Check AND LIST all that apply:

Chemicals Gasses Plants

Animals Flammable Biological Material

Reactive Recombinant DNA Equipment

Carcinogenic Bacteria Fume Hood

Toxic Viruses Biosafety Cabinet

Corrosive Fungi Laminar Clean Bench

Oxidizer Parasites Autoclave

Cryogen Human Source Material Centrifuge

Pharmaceuticals Insects Analytical Instruments

Page 1 of 3 Industrial Machinery Noise Producing Equip. Other Equipment

Detailed Project Description (attach separate sheet if necessary):

I AGREE TO SPONSOR (MINOR’S NAME), AND BY MY SIGNATURE BELOW, AGREE THAT:

. I have read, understand, and will adhere to the NAU “Minors in Research Laboratories or Animal Facilities” Policy. The potential hazard information signature sheet is attached.

. I have completed this Minor’s Hazard Specific Safety Training. Training was conducted by doing the following:

. Personal protective equipment appropriate for, and specific to, laboratory hazards will be provided.

. This individual will be supervised at all times while in the laboratory and never left alone.

. Their hours of work will comply with Federal Regulation 29 CFR 570.35.

. My laboratory is in full compliance with all applicable Northern Arizona University safety programs and regulations.

NAME OF PI/SPONSOR

SIGNATURE

DATE

I have read, understand, and will adhere to the NAU “Minors in Research Laboratories or Animal Facilities” Policy.

NAME OF MINOR

SIGNATURE

DATE

INSTITUTIONAL BIOSAFETY COMMITTEE APPROVAL DATE:

OFFICE OF REGULATORY COMPLIANCE APPROVAL: DATE:

Page 2 of 3 Please return completed forms to the Office of Regulatory Compliance via campus mail: PO Box 4137, or email: [email protected]

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