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ETHICS CHECKLIST Instead of completing a number of ethics checklists even when wildlife, human participants, etc. are not involved in the research, theses/dissertations shall include a declaration of non-use, placed after the approval sheet. For Thesis Proposal DECLARATION OF NON-USE I, (name) , declare that my research entitled ____________________________ will not involve human participants, wildlife and animals, nor will it involve the use of infectious agents and toxic substances. Name and Signature of Researcher Confirmed by: Name and Signature of Adviser For Thesis DECLARATION OF NON-USE Upon my honor, I, (name) , declare that my research entitled ____________________________ did not involve human participants, wildlife and animals, nor did it involve the use of infectious agents and toxic substances. Name and Signature of Researcher Confirmed by: Name and Signature of Adviser *In case toxic substances are used, the following checklist should be submitted for approval during the thesis proposal, and the approved checklist should be included in the thesis (after the declaration of non-use): CHECKLIST FOR THE USE OF TOXIC SUBSTANCES IN RESEARCH Research Title ________________________ Researcher ____________________________ I. Commercial Value The research aim to produce a product with commercial value Yes II. No List and amount of substances/chemical (toxic and non-toxic) that will be used during the conduct of research Chemical / Substance Amount NOTE: The proponent is required to read/ check the material safety data sheet (MSDS) for each of the chemical. MDS is a detailed description of the chemical’s composition and properties provided by the company where this chemical will be purchased. III. Toxicity/Hazard Assessment Chemical/Substance 1. 2. 3. 4. 5. 6. 7. 8. 9. These chemicals are in solid form These chemicals are in liquid form These chemicals are in gaseous form These chemical substances will be synthesized, and may have potential for misuse for unethical purposes These toxic chemicals will be used as components/materials to generate another product These toxic chemicals will be generated as byproducts of processes used in the research These chemicals are corrosive (can injure body tissue or corrode metals) These chemicals are flammable (have the potential to catch fire readily and burn in air) These chemicals are oxidizer and reactive (can explode or react violently with water or atmospheric oxygen) 10. 11. 12. 13. 14. 15. IV. These substances are toxins (substances that even in small amount can injure body tissues) The substances are mutagenic/carcinogenic (can cause mutation or cancer) The substances are allergenic (can cause adverse reaction to the immune system) The substances are irritants(can cause adverse reaction to the immune system) The substances are neurotoxins (can induce adverse effect on the central or peripheral nervous system) These chemicals have the potential risk of being released and cause damage to the environment (e.g. pollution) Preparedness YES 1. 2. 3. 4. 5. V. NO I have experience in handling toxic chemicals/substances I will be conducting the research/experiments within the University There is a designated and safe working area where I can perform the research In case of accident, the lab facility and personnel are capable of handling the emergency I am aware of the guidelines for the disposal of hazardous wastes Description of the procedure to be used in handling toxic substances Identified Ethical/Safety/Environmental Issues Procedures to address these issues I declare that to my best knowledge, all statements above are true. Name and Signature of Researcher Reviewed by: Name and Signature of Adviser Protocol Approved by: Names and Signatures of Defense Panel