Course Application

							                       Course Application for January 12 – 16, 2009

                         Controlling Laboratory Biorisks

                                International Biological Threat Reduction
                             Sandia National Laboratories, Albuquerque, NM

                                               In collaboration with



              The Frontline Healthcare Workers Safety Foundation, Ltd., of Atlanta, GA

All participants must submit an application to Frontline Foundation. The course size is limited to 16
participants. Possible selection criteria for attendance include current job position and research activities.
Individuals not selected for the Jan 12-16 course will be placed on a waiting list or considered for future
courses.

Name: _______________________________________________________________________________

Title: ________________________________________________________________________________

Citizenship: ___________________________________________________________________________

Email address:_________________________________________________________________________

Name of your organization: ______________________________________________

Type of organization (e.g. Academic, Government, Private sector): _____________________________

Facility Address: _______________________________________________________________________

______________________________________________________________________________________

How many total researchers (including graduate students/postdocs/technicians) are in your organization?

______________________________________________________________________________________

What are you hoping to gain from attending this course?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________


1. Please select your highest level of education. (choose only one)
Less than secondary school                      Bachelors degree
Secondary school                                Masters degree
Associate degree                                PhD, MD, DVM
2. Which BEST describes your role in working with the infectious agents and/or toxins present in your lab?
(choose only one)
Responsible for operations and maintenance of labs and equipment used for these infectious agents and/or toxins, but
do not conduct research on them
Conduct “hands-on” work on one or more of these infectious agents and/or toxins
Prepare reagents and supplies for these infectious agents and/or toxins, but do not conduct research on them
Supervise research on these infectious agents and/or toxins
I have no role in working with these infectious agents and/or toxins.


3. Which BEST describes your current job position? (choose only one)
Graduate student/research assistant                  Biosafety Professional
Lab director/supervisor/coordinator                  Biosecurity Professional
Principal investigator                               Staff scientist
Quality assurance/quality control                    Technician
Professor/teacher                                    Other (please specify) _____________

4. Which infectious agent(s) and/or toxin(s) are studied in your laboratory? (check all that apply)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

5. What biosafety level are the laboratories at your facility?
Biosafety Level 1 (BSL1 or P1)
Biosafety Level 2 (BSL2 or P2)
Biosafety Level 3 (BSL3 or P3)
Biosafety Level 4 (BSL4 or P4)

I do not know

6. Please indicate your degree of concern for the following scenarios involving the infectious agent and/or toxin
that your laboratory studies. (choose only one for each category)
                                              Very worried                                            Very unconcerned
                                                   7           6         5     4        3         2          1
Accidentally infecting people or animals or
 contaminating the environment outside lab                                                
Acquiring ability to infect new species                                                   
Could be used to intentionally cause harm                                                 
Laboratory-acquired infection                                                             


7. How would you rate your current understanding of biosafety? (choose only one for each category)

                  Poor                                       Excellent
                    5         4         3         2            1
                                                   

8. How would you rate your current understanding of biosecurity? (choose only one for each category)

                  Poor                                       Excellent
                    5         4         3         2            1
                                                   


                          Return completed application by November 14th to:
                                      Frontline Foundation
                                    ATTN: Sandia Training
                                 Three Dunwoody Park, Ste 103
                                       Atlanta, GA 30338
                                       fax: 678-781-5242
                         email: sandiatraining@frontlinefoundation.org