2016 Polk Regional Science and Engineering Fair
School Institutional Review Board (IRB)
(Please return by September 19, 2015)
Each school participating in the PRSEF must have an Institutional Review Board (IRB) to review projects involving human
subjects in advance of research to evaluate for potential risks. An Institutional Review Board (IRB), is a committee that,
according to federal regulations (45-CFR-46), must evaluate the potential physical and/or psychological risk of research
involving humans. All proposed human research must be reviewed and approved by an IRB before experimentation begins.
This includes review of any surveys or questionnaires to be used in a project.
An IRB must:
1. consist of a minimum of three members
2. include an educator
3. include a school administrator (preferably principal or vice principal),
4. include an individual who is knowledgeable about and capable of evaluating the physical and/or psychological
risk involved in a given study. This may be a medical doctor, nurse practitioner, physician’s assistant, registered nurse,
psychologist, licensed social worker or licensed clinical professional counselor. No Adult Sponsor, parent or other
relative of the student, the Qualified Scientist, or Designated Supervisor who oversees the project
may serve on the IRB reviewing that project. Additional members are recommended to help avoid
a potential conflict of interest and to increase the expertise of the committee.
School: Click here to enter text.
School Fair Coordinator: Click here to enter text.
1. IRB Chair’s Name: Click here to enter text.
Title:Click here to enter text.
Mailing Address: Click here to enter text.
Work Phone: Click here to enter text.
Fax Number: Click here to enter text.
School/Firm: Click here to enter text.
CityClick here to enter text., FL Zip:
Home or Cell Phone: Click here to enter text.
E-mail Address: Click here to enter text.
2. Name: Click here to enter text.
Title:Click here to enter text.
Mailing Address: Click here to enter text.
Work Phone: Click here to enter text.
Fax Number: Click here to enter text.
School/Firm: Click here to enter text.
CityClick here to enter text., FL Zip:
Home or Cell Phone: Click here to enter text.
E-mail Address: Click here to enter text.
3. Name: Click here to enter text.
Title:Click here to enter text.
Mailing Address: Click here to enter text.
Work Phone: Click here to enter text.
Fax Number: Click here to enter text.
School/Firm: Click here to enter text.
CityClick here to enter text., FL Zip:
Home or Cell Phone: Click here to enter text.
E-mail Address: Click here to enter text.
4. Name: Click here to enter text.
Title:Click here to enter text.
Mailing Address: Click here to enter text.
Work Phone: Click here to enter text.
Fax Number: Click here to enter text.
School/Firm: Click here to enter text.
CityClick here to enter text., FL Zip:
Home or Cell Phone: Click here to enter text.
E-mail Address: Click here to enter text.
___________________________________________ Date: __________________________
School Fair Coordinator Signature
After signing, return by September 19, 2015 to:
Kim Rex, District Office, Teaching and Learning, Route E.
Mailing Address: 1925 S. Floral Ave., Building F, Bartow, FL 33830