Permit Request • CampusOptics

Minors Research Proposal and Consent Form

Please complete the information below to obtain your Minor in Research Permit.

Completed proposals must be submitted to the Environmental Health and Safety (EHS) Office no fewer than two (2) weeks prior to the start of any research activities.

Contact EHS for assistance with any of the questions.

Requester Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Permit Date & Time

Start Date* Required

Start Time* Required

Expiration Date* Required

Expiration Time* Required

Location

Name* Required

Additional Location Details

Part 1: Information about the minor

Minor's Name (Last, First, MI): * Required

Phone:* Required

Email:* Required

Date of Birth: * Required

Age:* Required

Name of Principal Investigator (PI):* Required

PI's Email:* Required

Phone: * Required

Department: * Required

Supervisor (if different from PI):* Required

Email* Required

Work Location (if in the field, please specify where):* Required

Emergency Contact Information * Required

Parent/Guardian Name(s): * Required

Parent/Guardian Phone: * Required

Parent/Guardian Email: * Required

Emergency Contact Person’s Name (other than Parent/Guardian): * Required

Relationship to Minor: * Required

Emergency Contact Phone: * Required

Emergency Contact Email: * Required

Part 2: Research Hazard Identification

Work with biological agents at BSL-1 or BSL-2. Provide IBC registration number and list agents: * Required

Work with animals (in the research lab, IACUC approval required). Provide IACUC approval number and list animal species: * Required

Work with animals (in the field, IACUC approval required). Provide IACUC approval number and list animal species: * Required

Chemical use, list chemicals or attach a list: * Required

Equipment use, list type of equipment with potential associated hazards: * Required

Scientific Boating. Describe activity: * Required

Check any of the following that are applicable to the research being conducted: * Required

Scientific Snorkeling.
Scientific Diving.

Other potential hazards: * Required

Part 3. PI/Supervisor Certification

PI Name (VALID AS A DIGITAL SIGNATURE)* Required

Date* Required

Part 4. Parents/Guardians should review this form and sign the consent below.

RELEASE OF LIABILITY AND WAIVER AGREEMENT

Printed Name of Minor:* Required

Printed Name of Parent/Guardian (valid as a digital signature): * Required

Date:* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your permit request.

Files

Requester Info

Permit Date & Time

Location

Part 1: Information about the minor

Part 2: Research Hazard Identification More information

Part 3. PI/Supervisor Certification More information

Part 4. Parents/Guardians should review this form and sign the consent below. More information

RELEASE OF LIABILITY AND WAIVER AGREEMENT More information

Add Supporting Documents

Part 2: Research Hazard Identification

Part 3. PI/Supervisor Certification

Part 4. Parents/Guardians should review this form and sign the consent below.

RELEASE OF LIABILITY AND WAIVER AGREEMENT