FLASF Forms

Youth Science Foundation Canada

Application For Review of Research with Human Participants

(Print or type, attach additional sheets as necessary.)

(Forward Completed Form to Heather Highet.)

FLASF

1. Student Researcher(s):

Name	__________________________	Name	__________________________
Address	__________________________ __________________________	Address	__________________________ __________________________
Telephone	__________________________	Telephone	__________________________

2. Title of Project: ___________________________________________________________

3. Supervising Teacher: ______________________________________________________

School: ____________________________________ Telephone: __________________

Summary of Proposed Research

4. a) Briefly describe the purpose of this project.

_______________________________________________________________________

b) Briefly outline the general experimental procedure.

_______________________________________________________________________

5. a) Who, and what number of participants will be involved in this project?

_______________________________________________________________________

b) How will the participants be recruited for this project? (Attach a copy of any recruitment notice or letter)

_______________________________________________________________________

c) Outline what the participants will be expected to do. (e.g. surveys, interviews etc.) Attach a copy of test materials, surveys, questionnaires or interview questions to be used.

_______________________________________________________________________

6. a) What are the potential risks (physical, psychological, emotional) to the participants in this project ?

_______________________________________________________________________

b) What are the potential benefits of this project (e.g. to the participants, to society)?

_______________________________________________________________________

7. Will informed consent of the participants be informed in writing? If not, explain why. Attach a copy of the information consent form to be used.

_______________________________________________________________________

8. How will you ensure anonymity of the participants and confidentiality of their data?

_______________________________________________________________________

9. Describe your plans to provide feedback or a summary of the study to the participants.

_______________________________________________________________________

10. Additional Attachments: Sample letters of consent. parent permission letters and pre-medical screening forms should be attached.

I have read the YSF Canada Guidelines for Research with Human Subjects and agree to comply with the Guidelines. Further, I agree to notify YSF Canada or my regional science fair of any changes to this project.

Signature of Student Researcher _______________________________ Date: _____________

Signature of Supervising Teacher _______________________________ Date: _____________

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Ethics Review Committee Comments:

_______________________________________________________________________