Science Fair Form D – JUVENILE Contribution from a Recognized Institution Have this form completed electronically by the scientific sponsor

Preamble The Science Fair exhibitor* whom you have agreed to supervise has decided to present an experimentation project that, under the Science Fair Rules, requires completion of a “Contribution from a Recognized Institution” by the scientific sponsor. The latter is a person employed as a scientist by a recognized institution who undertakes, on its behalf, to justify the institution’s participation in the proposed project and to confirm the participation of a scientific supervisor. The scientific supervisor is a person employed as a scientist by the recognized institution who actively takes part in the project, for example by performing manipulations or experimentations, or by re-reading the report. This person ensures compliance with the codes of ethics and safety during the undertaking of the project.

This form is mandatory to ensure compliance with the codes of ethics and safety by exhibitors, but also whenever participation by professionals is required, for example to ensure a project is completed under conditions compliant with established standards in professional settings, for loaning of materials to which the exhibitor would not have access without professional assistance, and for any project requiring participation of human subjects.

This form is also used to estimate the extent of the contribution of the professional(s) involved and is an important document for project evaluation. The CDLS-CLS Network Provincial Ethics Committee is tasked with verifying the necessary approvals per the Science Fair Rules and may, at any time, put an end to a project deemed non-compliant. At any time, the Ethics Committee may contact the scientific sponsor for clarifications. If you have any questions, feel free to contact the Ethics Committee by email at: [email protected].

The sections of the form that are to be completed by the exhibitor must be completed BEFORE the form is given to the scientific sponsor. The scientific sponsor then validates the information and completes the remaining sections. After completing and signing the form, the scientific sponsor must give both an electronic and a print version back to the exhibitor.

The exhibitor must, based on the registration deadline, upload Form D, duly completed, when registering online for the Regional Final.

You may view the Science Fair Rules by visiting the Science Fair website at exposciences.qc.ca.

The CDLS-CLS Network thanks you for your cooperation.

CDLS-CLS Network – September 17, 2014 *A project may be developed with a partner (maximum two participants) Page 1 of 5 Form D - Contribution from a Recognized Institution (cont’d)

Section 1. General Information TO BE COMPLETED BY THE EXHIBITOR Year of participation:

Last name and first name of entrant 1 Last name and first name of entrant 2 (for a duo project)

Project title:

Regional Science Fair:

1.1. Science Fair project description

TO BE COMPLETED BY THE SCIENTIFIC SPONSOR

Name of Recognized Institution:

Address Phone Email address

Last name and first name of scientific sponsor Title and position of scientific sponsor

Last name and first name of scientific supervisor Title of scientific supervisor

1.2. Does your institution adhere to a recognized code of ethics for experimentation as concerns (depending on the subject of the Science Fair project that you wish to sponsor, a) or b): a. a safety code for handling of hazardous substances? Yes No

b. the Canadian Council on Animal Care (CCAC) Guidelines and Policy Statements? Yes No

1.3. Description of the institution’s contribution (e.g.: loan of materials or equipment, or support from professionals).

Please summarize the way in which your institution contributed to the above-mentioned project.

1.4. Scientific supervisor Please state the name of the person who will be acting as the project’s scientific supervisor. Please summarize this person’s qualifications in relation to the project and how he or she will be participating concretely in the project. In your capacity as scientific sponsor on behalf of the recognized institution, please state whether you yourself will also be acting as the project’s scientific supervisor.

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1.5. Will the project require: a. the use of live animals, or animal tissue or parts of animals? Yes No (complete sections 2 and 4) b. the use of micro-organisms, bacteria, viruses, mould or primitive organisms Yes No (complete sections 3 and 4)

Section 2. Use of Live Animals, Animal Tissue or Parts of Animals TO BE COMPLETED BY THE SCIENTIFIC SPONSOR 2.1. Species and manipulations planned (compliant with the Canadian Council on Animal Care (CCAC) Guidelines and Policy Statements) Are the manipulations conducted under the supervision of an ethics committee that adheres to the Canadian Council on Animal Care (CCAC) Guidelines and Policy Statements? Yes No

2.2. Please specify the type (e.g., vertebrates, cephalopods, invertebrates) and species used, and explain the manipulations.

2.3. Were animals sacrificed for the sole purpose of conducting the Science Fair project? Yes No The JUVENILE Science Fair Rules (Section 5.3) prohibit the sacrificing of animals for the sole purpose of meeting the requirements of a Science Fair project. Use of animals or parts of animals is permitted only if the animals or parts of animals are shared as part of an initiative responding to the recognized institution’s own needs. Section 3. Use of Micro-organisms, Bacteria, Viruses, Mould or Primitive Organisms TO BE COMPLETED BY THE SCIENTIFIC SPONSOR 3.1. Location of experimentation Please state where the manipulations are being conducted along with the names and qualifications of the team personnel assisting the exhibitor(s) in conducting the project.

3.2. Species and manipulations planned Please state the type (e.g., bacteria, viruses, algae) and genus or species used along with the manipulations planned. Specify whether the manipulations were conducted under the supervision of an ethics committee. Please state what best practices were to be followed by the exhibitor(s).

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3.3. Rules specific to the Science Fairs a. Does the biological material used come from a recognized supplier or laboratory? Yes No The Science Fair Rules (Section 5.4) allow only biological material that comes from a recognized supplier of biological material or a recognized laboratory. b. Does the project involve study of high-risk biological material (e.g., HIV)? Yes No In view of the severe risk to exhibitors, we favour projects in which manipulations of high-risk biological material, if required, are entrusted to qualified, experienced professionals. c. Does the project require the use of radioisotopes, ionizing radiation or radioactive substances? Yes No The Science Fair Rules (Section 10.9) prohibit experiences requiring the use of radioisotopes, ionizing radiation or radioactive substances.

Section 4. Other Provisions TO BE COMPLETED BY THE SCIENTIFIC SPONSOR 4.1. Presentation Have you discussed, or do you plan to discuss, the content of the exhibitor’s presentation with the exhibitor? Does the presentation faithfully reflect the exhibitor’s original contribution and also illustrate the contribution(s) of your institution’s professional(s)?

4.2. Written report Have you read, or do you plan to read, a version of the written report prepared by the exhibitor? Does the report faithfully reflect the exhibitor’s original contribution and also illustrate the contribution(s) of your institution’s professional(s), as well as provide a thorough bibliography?

4.3. Usage authorizations Is the exhibitor authorized to present the research results in public? Yes No Is the exhibitor authorized to show a photo of you or your team in public? Yes No

Provide details, if necessary

Section 5. Commitments TO BE COMPLETED BY THE SCIENTIFIC SPONSOR 5.1. Commitments of the recognized institution and scientific sponsor (during conducting of the project in your institution) By signing below, I certify that:

a. I have read and understand the Science Fair Rules Yes No

b. I have completed all of the required sections of this form (1, 4) Yes No

c. I have completed all of the sections relating to the proposed project (2 or 3) Yes No

d. I have notified and raised the exhibitor’s awareness of the various ethical & safety rules in effect Yes No

e. I am responsible for compliance with the ethical & safety rules on behalf of the recognized institution Yes No

f. the scientific supervisor was/will be present for the various stages of the project Yes No

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Signature of scientific sponsor

Signed on: at

Last name and first name of scientific sponsor Signature of scientific sponsor

Signature of exhibitor(s)

Signed on: at

Last name and first name of Exhibitor 1 Last name and first name of Exhibitor 2 (for a duo project)

Signature of Exhibitor 1 Signature of Exhibitor 2 (for a duo project)

TO BE COMPLETED BY THE CDLS-CLS NETWORK PROVINCIAL ETHICS COMMITTEE

For all projects carried out in a recognized institution The exhibitor must submit Form D, completed and signed, and upload it at the time of online registration for the Regional Final. He or she must obtain the signature of a member of the CDLS-CLS Network Provincial Ethics Committee to receive approval of project compliance.

Signed on: at

Last name and first name of a member Signature of a member of the CDLS-CLS Network Provincial Ethics Committee of the CDLS-CLS Network Provincial Ethics Committee

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