curf - Center for Undergraduate Research & Fellowships

Penn

RESEARCH EXPERIENCE RELEASE AND WAIVER OF LIABILITY FORM

Name of Grant Received:

First Name:

Last Name:

Penn Email:

Penn ID Number:

School (select all that apply using CTRL+click):

Expected Graduation Year

Experience Location

Location 1 City

Location 1 Country

Location 1 Start Date

Location 1 End Date

Location 2 City

Location 2 Country

Location 2 Start Date

Location 2 End Date

Additional locations:

Emergency Contacts

Contact 1 Name

Contact 1 Relationship

Contact 1 Phone

Contact 1 Email

Contact 2 Name

Contact 2 Relationship

Contact 2 Phone

Contact 2 Email

Additional Contacts:

Communications access for you during research experience

Please list at least two other individuals who will be able to reach you.

Contact 1 Name

Contact 1 Relationship

Contact 1 Phone

Contact 1 Email

Contact 2 Name

Contact 2 Relationship

Contact 2 Phone

Contact 2 Email

Additional Contacts:

Mentor/Affiliate or organizational contact for experience

Mentor 1 Name

Mentor 1 Organization/affiliation

Mentor 1 Phone

Mentor 1 Email

Nature of mentoring/assistance provided:

Mentor 2 Name

Mentor 2 Organization/affiliation

Mentor 2 Phone

Mentor 2 Email

Nature of mentoring/assistance provided:

Institutional Review Board (IRB) Requirements for Research Experience

By checking the boxes below, you are indicating that you have completed the specified activity and provided all requested documentation

Review http://www.upenn.edu/regulatoryaffairs/Documents/irbgui-1.pdf. Does your project require Institutional Review Board review?

Yes
No

If you checked “Yes” and IRB review is required, you must work with your faculty advisor to prepare and submit either the Claim of Exemption or IRB application to Penn’s Institutional Review Board. (Students cannot submit applications directly for IRB review without a faculty sponsor). A copy of the IRB Letter of Approval or IRB Approval of Exemption must be submitted to CURF before funding will be released. Aspects of a research project requiring IRB approval cannot begin and CURF funding will not be allocated until any necessary IRB approval/exemption is obtained and documented.
Have a plan in place to obtain informed consent of any subjects to use their voice, image or any identifiable data. Have a plan for use and storage of such data that ensures confidentiality. Note: if video, audio or any other data could potentially be used publicly – e.g., on the internet – that consent must be specifically obtained from all subjects and those consent forms retained by the researcher.

Patent Policy Regulations for Research

Review University Patent Policy http://www.med.upenn.edu/postdoc/documents/patent.policy.02.22.05.pdf (particularly Section 2.1.4.1 – Student Inventions) Does your project require completion of Patent Policy Participation Agreement?

Yes
No

If yes, complete and submit to CURF a signed copy of Appendix A – “Participation Agreement”


Check if you are traveling internationally.

IF YOU ARE TRAVELING INTERNATIONALLY: Checklist of Requirements for International Experience

Register your trip on Penn’s Global Activities Registry
Register your travel plans online with the Department of State
Visit Department of State Travel Warnings webpage. Is there a travel warning for your destination?:

Yes
No

Review all info on Global Health Programs website Travel Page:
Review CDC’s National Center for Infectious Diseases’ Traveler’s Health website (Tips for Travelers &Destinations)
Make an appointment for a travel consultation & immunizations (as soon as possible) at Penn’s Travel Services in Student Health or with the physician or medical group of your choice that has expertise in travel health/medicine
Complete recommended vaccinations (can require 6 months) and obtain prophylactic medications
Ensure that you have your passport and all visa/country entry documents in order
Review the scope of your health insurance coverage; obtain additional coverage as needed
International SOS: review coverage and be sure to have membership & contact information with you when traveling

Upload any required IRB approval or exemption letters here, combined into one .pdf document and named using your PennKey name:

In consideration of my participation in the international experience described on the previous page(s), I, the undersigned student, acknowledge and agree to the following conditions:

I understand that my participation in the experience may expose me to significant risks, including, but not limited to, crime, terrorism, war, exposure to communicable diseases, the hazards of travel by airplane, vehicle and foot, serious bodily injury or death, property damage and other risks that may not be foreseeable. I recognize that the University cannot guarantee my safety and I understand that I am solely responsible for my safety and I assume responsibility for all risks associated with my participation in the experience.

I know that I am not required to participate in this experience in order to satisfy any requirements of the University of Pennsylvania, even though this experience may be an approved part of my education.

I understand and accept that, as a participant in the experience, I am required to observe the laws of the country in which I will be residing and all academic and disciplinary regulations in effect at the host institution. I further understand and accept that while participating in the experience I will remain enrolled concurrently as a degree candidate at the University of Pennsylvania and, as such, I agree to adhere to the University’s Statement on General Conduct and Code for Academic Integrity. I realize that violation of the foregoing and/or academic failure or disciplinary disturbances may constitute grounds for my expulsion from the experience and referral of any violations to the Student Standards Committee.

I am informed that the University strongly recommends that students studying abroad obtain insurance coverage valid overseas to protect against the costs of hospitalization and medical care in the event of sickness, accident, disability, or death, and to offset expenses of unexpected emergency evacuation and repatriation, trip cancellation, or loss of property. I understand that I am solely responsible for obtaining Travel and Health Insurance for myself.

I confirm that I have been advised to consult the US Department of State resources for information regarding travel to the country in which the experience will occur and that I have made the decision to participate in the experience despite any warning or advisory regarding travel to that country.

I agree to participate in any orientation required for the experience and to obtain medical travel advice and immunizations appropriate for any country in which travel is planned.

I understand that the University of Pennsylvania accepts no responsibility for any delay, loss, damage or injury to person or property caused to others or me whether prior to departure, during travel or while participating in the experience abroad. Further, the University shall not be responsible to any person for any of my acts or omissions, except to the extent that my activities are within the scope of approved activities covered under the University’s general liability insurance.

I agree to hold harmless, release and forever discharge the University and its trustees, officers, employees and agents from any and all claims, demands and causes of action of whatever kind that I may have including, but not limited to, illness, bodily injury, imprisonment, death and loss or damage to property, or the consequences thereof, resulting from or in any way connected with my participation in the experience.

My participation in this experience is voluntary, and I freely agree to the stipulations of this waiver. By signing below, I certify that I am at least 18 years of age and that I have carefully read this Release and Waiver of Liability, understand it, and agree to be legally bound by it, that I have fulfilled the checklist requirements on the previous page(s), and that all of the information I have provided in this form and in all attachments is accurate.

By clicking “submit” I am acknowledging that my PennKey will act as my signature, and the system timestamp will serve as signing date.


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