Siemens Competition Math : Science : Technology 2011 mentor form




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Siemens Competition

Math : Science : Technology

2011 MENTOR FORM


DIRECTIONS:

  • Each individual or team must have his or her mentor complete this form. The mentor should be the student(s)’ research supervisor or another qualified scientist who gave support throughout the course of the research project. If the student does not have a mentor, a teacher or other high school administrator must complete the form.




  • Please complete this form and be as detailed as possible. Projects will be disqualified if required information is not provided.




  • Use student(s)’ names and high school only on the first page of this form. Do not use names or reference to their gender, high schools, research labs, mentors, or school officials in your answers to the questions on the following pages. You may use generic terms, such as “student” or “team leader” or “team member #2.”




  • Section V of this form, Human Subjects or Other Vertebrate Certification, must be completed and signed by the mentor or supervising scientist if the Research Project utilizes any vertebrate animals, including human subjects. This information must be properly completed and will be carefully reviewed to determine the project's eligibility in accordance with the rules of this competition. Guidelines for Projects with Human Subjects and Other Vertebrates can be found on the last page of this form.




  • You must type your answers directly onto this form (www.collegeboard.com/siemens). Other letters of reference are not solicited and will not be considered.




  • The mentor should place one original and three copies (four total) of this form into a sealed envelope and give it to the student for submission with the research report. If the mentor prefers, s/he can mail the completed mentor form and copies directly to the address below. All mentor forms and other materials must be received by 5:00 p.m. ET, October 3, 2011. Faxed forms will not be accepted.




  • Mail Completed Forms to:

For Regular Mail:

For Overnight Mail or Hand Delivery Only:

Siemens Competition

Educational Testing Service

PO Box 6730

Princeton, NJ 08541



Siemens Competition

Educational Testing Service

1425 Lower Ferry Road, Room Q220

Trenton, NJ 08618

Telephone: (609) 771-7878


If you have questions while completing the form, please contact the College Board’s Siemens Scholarship Program at 877-358-6777 or email us at spro@collegeboard.org.


SECTION I – STUDENT INFORMATION (must be typed)

Research Project Title:

     

Project Confirmation Number:

(Provided on student’s Confirmation Page)



     

Type of Research Report:

(Individual, Two-person team, Three-person team)



     

Name of Individual or Team Leader:

     

Name of Individual’s or Team Leader’s High School:

     

High School City and State:

     

Name of Team Member 2:

     

Name of Team Member 3:

     

Are you or the supervising scientist/lab director related to any of the students?

Yes/No:      

If yes, please state the relationship.

     



SECTION II – MENTOR COMMENTS (must be typed)


  1. Provide specific details on the contributions of the following individuals on the origin and design of the project:

  1. Student(s)

     


  1. You, the mentor

     


  1. Other(s) including those involved in prior or concurrent work relevant to this project

     


  1. Provide specific details on the contribution of the following individuals on the execution, analysis and interpretation of the project:

    1. Student(s)

     


    1. You, the mentor

     


    1. Other(s)

     


  1. Describe how much of the written report is the original work and language of the following:

    1. Student(s)

     


    1. You, the mentor

     


    1. Other(s)

     


    1. Previous documents/publications of the research group

     


  1. For a team project, comment on the collaborative efforts of the team and how each member contributed to the total research project:

     


  1. What was the duration of the student’s research program at your institution? Specify the time period in months/years (e.g. 6/05 to 8/06):      



  1. Has this research project been published, submitted for publication, or are there plans to submit this for publication in the future? Enter “X” in one of the following:

      No       Yes – Published       Yes – Accepted       Yes – Submitted/Will be Submitted


  1. If yes, please provide information on the publication(s), whether the student will be listed as a contributor or co-author and what part of the writing was done by the student. The students and/or the mentor may be required to submit a copy of the manuscript, if requested. 

     




SECTION III – MENTOR INFORMATION (must be typed)

Name of Person Completing Form:

     

Are you the mentor? (Yes/No)

     

If no, are you a high school administrator/teacher? ( Yes/No)

     

Position/Title:

     

Institution/Affiliation:

     

Address:

     

City:

     

State:

     

Zip Code:

     

Phone:

     

Email:

     

I certify that all the information given above is correct to the best of my knowledge and I understand that should the student or myself make any false statements, the College Board and the Siemens Foundation reserve the right to disqualify the project. I certify the student(s) has/have been advised of safe practices in the handling and disposal of hazardous materials, if any. I authorize this project to be submitted to the Siemens Competition.

Signature:




Date:

     


Answer the following questions and follow the instructions as noted:


  1. Was the research completed in an authorized laboratory or research institution? Yes/No:      

  • If Yes, COMPLETE SECTION IV




  1. Did this project use an established cell line and/or material from tissue banks? (Projects using established human or animal cell lines do not require IACUC or IRB approval.) Yes/No:      

  • If Yes, COMPLETE SECTION IV




  1. Did this project use live human subjects or other live vertebrates; or fluids, cells, tissues, or organs of vertebrate origin? Yes/No:      




  1. Is a mathematics project and therefore not done in a research laboratory? Yes/No:      

  • If Yes, STOP HERE




  1. None of the above applies. Yes/No:      

  • If Yes, STOP HERE




SECTION IV – REQUIRED AUTHORIZATION BY LABORATORY DIRECTOR (must be typed)

This section is required to be filled out by the Laboratory Director if the research was completed in a laboratory or research institution. However, if the Mentor is the Laboratory Director, only note “Same as Above” in the space for Name. If there is no Laboratory Director, indicate “None” in the space for Name.

Name of Laboratory Director:

     

Title:

     

Institution/Affiliation:

     

Address:

     

City:

     

State:

     

Zip Code:

     

Phone Number:

     

Email:

     

I authorize this project to be submitted to the Siemens Competition.

Signature:




Date:

     


SECTION V – HUMAN SUBJECTS OR OTHER VERTEBRATE CERTIFICATION (must be typed)

This section is required for all projects involving any vertebrate, including human subjects, and must be completed and signed by the project mentor or the supervising scientist at the research institution. Guidelines for Projects with Human Subjects and Other Vertebrates can be found on the last page of this form.


Project Confirmation Number:

(Provided on Confirmation Page after student registers)



     

Name of Individual or Team Leader:

     

Name of Institution where the research was conducted:

     


Answer the following questions and follow the instructions as noted:
1. Did this project use Live Non-Human Vertebrates? Yes/No:      

  • If Yes, COMPLETE SECTION A

2. Did this project use Non-Living Materials (i.e. tissues, cells, organs or fluids) from Vertebrates? Yes/No:      



  • If Yes, COMPLETE SECTION B

3. Did this project use Human Subjects or Human Materials? Yes/No:      



  • If Yes, COMPLETE SECTION C



SECTION A – Complete for Projects Involving Live Non-Human Vertebrates




  1. Title of Institutional Research Study as approved by the IACUC:      




  1. IACUC Approval #:      




  1. IACUC Approval Date:      




  1. Identify the genus, species, common name and tissue(s) or organ(s) of the animals in the student(s)’ project.

     


  1. Describe in detail the student(s)’ interaction with live animals.

     


  1. Explain why this interaction was necessary for the student(s)’ research.

     


  1. Explain what happened to the live animals after the student’s research. For example, were the animals used for other research, euthanized, or disposed of by other means. Please provide specific detail.

     


  1. Did this study also use non-living materials from vertebrates? Yes/No:      

  • If Yes, COMPLETE SECTION B







SECTION B – Complete for Projects Involving Non-Living Materials from Non-Human Vertebrates

  1. Title of Institutional Research Study as approved by the IACUC:      




  1. IACUC Approval #:      




  1. IACUC Approval Date:      




  1. Identify the genus, species, common name and tissue(s) or organ(s) of the animals in the student(s)’ project.

     


  1. Explain in detail the student(s)’ acquisition and use of these materials.

     


  1. For this competition animals cannot be euthanized for the sole purpose of the student(s)’ research. Explain how your student(s)’ materials meet this requirement and describe the primary purpose for which the animals were euthanized. Include specific detail regarding the other study involved.      

SECTION C – Complete for Projects Involving Human Subjects or Human Materials




  1. Title of Institutional Research Study as approved by the IRB:      




  1. IRB Approval #:      



  1. IRB Approval Date:      

If the IRB has determined that your project is exempt, type “Exempt” next to IRB Approval # and attach documentation of exemption.


  1. Explain why human subjects or human materials are necessary for this project.

     


  1. Describe in detail the involvement of human subjects or human materials in the student(s)’ research.

     


REQUIRED CERTIFICATION SIGN-OFF (must be typed)


I certify that the student(s)’ project was conducted in a registered institution or laboratory and that the student(s) worked with humans, live vertebrates or non-living materials from vertebrates under the direct oversight of the supervising scientist. If requested, I will provide documentation of the IACUC/IRB approval. I further certify that no animals (vertebrates) were euthanized for the sole purpose of the student(s)’ research project and will provide supporting documentation if requested.


Name of Person Completing Certification:

     

Are you the Mentor or Supervising Scientist at the research institute:

     

Position/Title:

     

Institution/Affiliation:

     

Address:

     

City:

     

State:

     

Zip Code:

     

Phone Number:

     

Email:

     

Signature:




Date:

     



Guidelines for Projects with Human Subjects and Other Vertebrates


For the purpose of this Competition, live vertebrates include humans, mammalian embryo or fetus, bird eggs within three days (72 hours) of hatching, and all other vertebrates at hatching or birth. Section V of the Mentor Form, Human Subjects or Other Vertebrate Certification, must be completed by the advisor, mentor or supervising scientist. In addition, the student must answer the Qualification Questions for Vertebrate Animals/Human Subjects, as explained under Additional Required Materials.

Projects that involve in any way, including testing and questioning, the use of live human subjects or other live vertebrates or the fluids, cells, tissues or organs from vertebrates are accepted only under the following conditions:



  1. The research project is conducted in a registered institution or laboratory in the United States where human or animal experimentation is authorized. The mentor(s) is required to provide the following information on the certification form:

    • Name of the research institution

    • Title of the study

    • In the case of human subjects, Institutional Review Board (IRB) approval number and approval date; a high school IRB is not permitted

    • In the case of other vertebrate animals, Institutional Animal Care and Use Committee (IACUC) approval number and approval date

  1. The vertebrate animals cannot be euthanized for the sole purpose of the student's research project. Fluids, cells, tissues and organs may be used only if the animals were euthanized for another purpose.

  2. Projects using established human or animal cell lines do not require IACUC or IRB approval.

Research projects conducted outside of the United States must follow the same guidelines listed above when using live human subjects or other live vertebrates or the fluids, cells, tissues or organs from vertebrates in accordance with the following:

  • The research must be done in an institution that is affiliated with a U.S. registered institution or laboratory. The mentor must provide an IRB or IACUC approval number; or

  • The country where the research is done must have, at a minimum, guidelines equivalent to the United States. The mentor must provide evidence of this. In place of an IRB or IACUC approval number, the mentor must provide a copy of the official certification used in that country and specifically for that research project. If the country or affiliate institution has a federal-wide assurance number, please provide. The documentation must be in English.







2011


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