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Acknowledgement and Release ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ STUDENT

First Middle Last


As a WISP intern for the 2013-2014 academic year; !I agree to complete two terms of a paid part-time research internship with the faculty sponsor named below. First year students are expected to start in January and work winter and spring terms. Sophomores can work any two terms between winter, spring and summer terms. *Please indicate which terms you plan to work in consultation with your sponsor: ______________________________________

understand that I am expected to: o Keep track of my hours and turn in biweekly timesheets, signed by my sponsor. o Present a poster at the Karen Wetterhahn Science Symposium in May. o Respond to questionnaires preceding and following the internship o Participate in intern group discussions have consulted with my sponsor and understand that I need to complete training in the areas indicated below: __Environmental Health and Safety (EHS) __Committee to Protect Human Subjects (CPHS) __Responsible Conduct of Research (RCR)


Student Signature


~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ SPONSOR
Name: Department: HB:

I agree to supervise the above named student as my WISP intern for two terms as designated above during the 20132014 academic year I, or someone else in my lab, will sign the students biweekly timesheets. I will ensure that the student is aware of the appropriate practices within the research laboratory space and/or associated facilities and complies with applicable policies regarding the use of the space, including safety related policies. If applicable, I will ensure that my WISP intern completes the on-line Environmental Health and Safety Training Module before beginning the internship. If the WISP intern involves human subjects research, interviews, or survey procedures, I understand that I am the Principal Investigator for the project and responsible for obtaining approval from the Committee for the Protection of Human Subjects (CPHS). I will ensure that my WISP intern completes the appropriate Institutional Review Board educational sessions. If project is funded through NSF, I will ensure that my WISP intern completes training in Responsible Conduct of Research (RCR).

Sponsor Signature (required) Assistant Sponsor Signature (if applicable)

Date Date

Return signed and completed form to the Women in Science Project, HB 6243, Parker House by Friday, January 10, 2014