FOR OFFICE USE ONLY
Biohazard Containment Certificate
CONFIDENTIAL
PROTOCOL NUMBER: EXPIRY DATE:
In accord with Laurentian University Biosafety Program, this form must be submitted to and approved by the Biosafety Officer prior to commencing projects involving biological hazards. Any proposed changes, including but not limited to personnel, agents, location or procedures that may affect the required level of containment, shall be submitted to the Biosafety Officer for approval prior to implementing the change(s).
1
Surname
PRINCIPAL INVESTIGATOR OR COURSE DIRECTOR First Name
Rank / Position Department / Faculty Business Telephone Emergency Telephone Mailing Address Laboratory Telephone Email Address Residence Telephone
NAME OF DESIGNATED ALTERNATE FOR EMERGENCIES
A. Faculty (mandatory)
Name
Rank
Emergency Telephone
2
PROJECT Title (including course number if applicable)
Primary Location (building, room)
Secondary Location (including testing rooms, storage areas)
3
FUNDING Agencies: Application Number(s): Status of Grant:
External
Internal Source:
Status of Funding: Status of Peer Review:
Status of Peer Review:
4 5
DATES Proposed start date of research: Expected date of completion: TYPE OF EXPERIMENT Research Check all applicable boxes Testing Research/Teaching OR ongoing? OR ongoing?
Teaching
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July 2009
6
DESCRIPTION OF PROJECT AND PROCEDURES Describe in DETAIL all procedures and techniques to be used, emphasizing those performed on animals. Use flow charts to illustrate procedures as appropriate. Append additional page(s) if necessary. Copies of complete grant applications will not be accepted.
7
BIOLOGICAL AGENTS: Check all that apply Bacteria Viruses Fungi Parasites Primary human cell cultures Established human cell lines Human tissues and cells Human blood/blood fractions Established animal cell lines Animal tissues and cells Animal body fluids Animal blood/blood fraction Recombinant DNA/RNA IDENTIFY BIOLOGICAL AGENTS (S)
ID 0
Name
Risk Group
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Export or Import Certificate required
Transportation off-site required
8
RESEARCH PERSONEL
ID 0
Name
Job Title
Training
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Remove Row
9
SPECIAL REQUIREMENTS (ethics, release time, renovations, etc.)
Indicate each that apply: Use of human subjects Use of animals Use of radioactive material None of the above approval pending approval pending approval pending approved approved approve Provide REB Protocol # Provide ACC Protocol # Provide Isotope License #
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July 2009
18
DECLARATION AND SIGNATURE All biohazards used in this research, teaching or testing proposal will be maintained and used in accordance with the recommendations of the Public Health Agency, as stated in the Laboratory Biosafety Guidelines, 3rd edition, and other applicable Laurentian University policies and procedures.
Principal Investigator or Course Director
Date
19
APPROVALS Chairperson, Biosafety Committee
Extension
Signature
Date
Biosafety Officer
Extension
Signature
Date
NOTE: THIS FORM CANNOT BE PROCESSED UNLESS ALL SECTIONS ARE COMPLETED.
THE PROTOCOL SUBMITTED IS SUBJECT TO APPROVAL BY THE BIOSAFETY COMMITTEE. SHOULD AMENDMENTS TO PROJECTS OR PROCEDURES BE DEEMED NECESSARY, THE RESEARCHER MUST COMPLETE A PROTOCOL AMENDMENT FORM. THE APPROVED FORM SHALL BE APPENDED TO THIS PROTOCOL. PROTOCOLS ARE VALID FOR A PERIOD OF ONE YEAR FROM THE DATE OF APPROVAL BY THE UNIVERSITY BIOSAFEYTY COMMITTEE. A NEW PROTOCOL MUST BE SUBMITTED EACH YEAR.
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July 2009