Form B – Free and Individual Consent – Project Requiring Participation of Human Subjects(cont)

Science Fair

Form B

Free and individual consent

Project requiring participation of human subjects

Preamble

You have been approached by a Science Fair exhibitor* who has decided to present an Experimentation project requiring activeparticipation by human subjects.

The Science Fair Rules state that exhibitorsmust have obtained approval from theCDLS-CLS Network Provincial Ethics CommitteeBEFOREbeginningexperimentation, to ensure that theirproject complies with the Code of Ethics.

As a participant in the project, you must give your free consentby completing this form. It is important that you be informed of the benefits as well as the risks associated with your involvement. Before signing this form, please read all the information in it carefully, and check that the scientific sponsor has completed and signed his or her section.

You may consult the Rules by asking the exhibitor for a copy, or by visiting the Science Fair website at: exposciences.qc.ca.

THE EXHIBITOR MUST:

obtain validation from theCDLS-CLS Network Provincial Ethics Committeebefore beginning any experimentation requiring the active participation of human subjects;

have Form A duly completed by the scientific sponsor and signedby a member of theCDLS-CLS Network Provincial Ethics Committee;

have theoriginal of Form B completed electronically by the scientific sponsor andadd the required signatures;

print and make copies of Form B so that participants can sign it and declare that they have freely given their consent;

give signedcopies back to all participants;

present all duly signed copies of Form B in a ringed binderat the time of the Rules verification, during booth set-up at the Regional Final.

The CDLS-CLS Network partners thank you for your co-operation.

TO BE COMPLETED BY THE EXHIBITOR

Year of participation:
Regional Science Fair:
Project title:
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

TO BE COMPLETED BY THESCIENTIFIC SPONSOR

Last name and first name of the scientific sponsor / Title and occupation of the scientific sponsor
Name of the recognized institution / Name of scientific supervisor
Contact information for the recognized institution
Address / Phone number / Email
Signature of scientific supervisor

TO BE COMPLETED BY THE EXHIBITOR

1.Description of project
2.Tasks requested of the participant
3. Benefits of participation
4. Risks of participation
5. Period of time to be devoted to the experiment by the human subject
Confidentiality of data
All documents (research data, consent forms, etc.) must be stored separately until the end of the project. After participation in the various competitive levels of the Science Fair is complete, all documents will be destroyed, and no personal information will be preserved on any medium whatsoever (e.g., paper, electronic).
Withdrawal
You freely and voluntarily consent, without any outside constraints or pressure, to participate in the project. You have the right to withdraw from the project at any time, for any reason. If you do intend to withdraw, please advise the Science Fair exhibitor in writing before doing so. At that point, all information concerning you will be destroyed.
Consent
I declare that I:
•have read and understood this consent form as well as the nature and degree of my participation, and the risks and inconvenience to which I am exposed;
•have had the opportunity to ask any questions that I had about any aspectof the project;
•voluntarily agree to participatein this project;
•have been informed that I may withdraw from this project at any time, without any penalty whatsoever;
•have been given enough timeto make mydecision.
By signing below, you agree to take part in the experiment.
For a participant aged 18 and older
Last name and first name of participant:
Telephone:
Signature: / Date:
For a participant aged under 18, authorization from a parent or legal guardian is required.
I agree that the person named hereunder may take part in the experiment in question.
Last name and first name of participant:
Signature of parent or guardian:
Telephone: / Date:

CDLS-CLS Network – September 16, 2014*A project may be developed with a partner (maximum two exhibitors)Page 1of2