Health, Safety
& Environment
University of Regina Biosafety Questionnaire
(Appendix 6 of Biosafety Program)
Academic Staff Members and supervisors of research and teaching areas that use, store or dispose of biological
materials or organisms in University of Regina laboratories/facilities are requested to complete a Biosafety
Questionnaire annually to assist with obtaining a University-wide biological inventory. Once complete, please
forward to the Biosafety Officer (Human Resources).
Principal Investigator
Name:
Department/Unit:
Office Phone:
Email:
Staff, Students & Volunteers
Please list all your current laboratory staff, students and volunteers.
Name
Work Phone
2012-03 page 1
Section 1
1.
Biosafety Questionnaire
Does or will your laboratory group use or store whole soil, water or plant samples?
YES – complete Section 2
NO
2.
Does or will your laboratory group use microorganisms?
(e.g. bacteria, toxins, viruses, fungi, protozoa, parasites, or prions)
YES – complete Section 3
NO
3.
Does or will your laboratory group use recombinant DNA and genetic manipulation techniques?
YES – complete Section 4
NO
4.
Does or will your laboratory group use primary or established cell lines (culture)?
YES – complete Section 5
NO
5.
Does or will your laboratory group use animals or material derived from animals?
(e.g. blood, body fluids, tissues, carcasses)
YES – complete Section 6
NO
6.
Does or will your laboratory group use material derived from humans?
(e.g. blood, body fluids, tissues)
YES – complete Section 7
NO
7.
Does or will your laboratory group work with any other type of unfixed biological material or organism in your
laboratory?
YES – complete Section 2
NO
2012-03 Biosafety Questionnaire page 2
Section 2
Whole Water, Soil, and Plant Samples
Please give a brief 1-2 sentence description of the type of material worked with below
(e.g. biological and chemical water quality testing, treated sewage, identification of grass species
Section 3
Biological Materials or Organisms
Please list all biological materials or organisms that your laboratory group uses or stores below.
Biological:
Include all biologicals such as bacteria, toxins, viruses, fungi, protozoa, parasites, prions, etc.
Risk Group 1 or 2:
According to the Public Health Agency of Canada’s Laboratory Biosafety Guidelines, 2004,
Chapter 4. See Appendices of the Biosafety Program for a guidance list. If unknown,
indicate “unknown”.
Host Ranges:
Is this biological an actual or potential human, animal or plant pathogen?
Activity Used:
Teaching or Research
Person Responsible:
Principle Investigator/Laboratory Instructor name
Location Material is Used/Stored: Building, room number, freezer, etc.
Biological
Risk
Group
Host Ranges
Activity
Used
Person Responsible
Location Material is
Used/Stored
* Please attach additional pages if necessary
2012-03 Biosafety Questionnaire page 3
Section 4
Recombinant DNA and Genetic Manipulation
Please complete the Research Involving Recombinant DNA and Genetic Manipulation form (Biosafety Program
Appendices) and forward the completed form with this Questionnaire to the Biosafety Officer.
Section 5
Cell Lines (Culture)
Please list all cell lines that your laboratory group uses or stores below. Cells or primary cultures from animals and
humans known or reasonably suspected to be infected should be in the risk group for the suspected agent.
Cell line:
All clones and variants need not be listed unless they would be at a different Risk Level
Origin:
Species and tissue/organ (e.g. mouse mammary gland)
Transformed:
Name chemical, oncogene (if known) (e.g. SV-40 human oncogenic virus)
Risk Group 1 or 2:
According to the Public Health Agency of Canada’s Laboratory Biosafety Guidelines, 2004,
Chapter 4. See Appendices of the Biosafety Program for a guidance list. If unknown,
indicate “unknown”.
Person Responsible:
Principle Investigator/Laboratory Instructor name
Location Material is Used/Stored: Building, room number, freezer, etc.
Cell Line
Species & Tissue
of Origin
Transformed
Risk
Group
Person Responsible
Location Material is
Used/Stored
* Please attach additional pages if necessary
Section 6
1.
Animals
Are any agents listed in Sections 2-5 being used in any animals, even if just to carry a cell line?
YES
NO
Please list all materials derived from animals that your laboratory group uses or stores below. Materials derived
from animals should be considered as potentially infectious and zoonotic diseases must be considered. At the
University of Regina all animal work involving healthy animals or tissues is deemed Containment Level 1, whereas
working with diseased or intentionally diseased animals is designated Containment Level 2.
2012-03 Biosafety Questionnaire page 4
Material:
Description of tissue or body fluid
Species of Origin:
Species of animal
Specimen Source:
e.g. clinical sample, Red Cross, commercial animal breeding facility, fieldwork
Risk Group 1 or 2:
According to the Public Health Agency of Canada’s Laboratory Biosafety
Guidelines, 2004, Chapter 4. See Appendices of the Biosafety Program for a
guidance list. If unknown, indicate “unknown”.
Person Responsible:
Principle Investigator/Laboratory Instructor name
Location Material is Used/Stored: Building, room number, freezer, etc.
Material
Species of Origin
Specimen
Source
Risk
Group
Person Responsible
Location Material is
Used/Stored
* Please attach additional pages if necessary
Section 7
Humans
Please list all materials derived from humans that your laboratory group uses or stores below. At the University of
Regina all material derived from humans should be considered potentially infectious (as per Universal
Precautions). All work with human blood, tissues and fluids, regardless of source, needs to be handled at
Containment Level 2.
Material:
Description of tissue or body fluid
Species of Origin:
Species name
Specimen Source:
e.g. clinical sample, Red Cross, commercial animal breeding facility, fieldwork
Risk Group 1 or 2:
According to the Public Health Agency of Canada’s Laboratory Biosafety
Guidelines, 2004, Chapter 4. See Appendices of the Biosafety Program for a
guidance list. If unknown, indicate “unknown”.
Person Responsible:
Principle Investigator/Laboratory Instructor name
Location Material is Used/Stored: Building, room number, freezer, etc.
2012-03 Biosafety Questionnaire page 5
Material
Species of Origin
Specimen
Source
Risk
Group
Person Responsible
Location Material is
Used/Stored
* Please attach additional pages if necessary
Please submit completed form:
by mail to Health, Safety & Environment, Human Resources
or, by e-mail to health.safety@uregina.ca
2012-03 Biosafety Questionnaire page 6