Biosafety Registration Form
AMENDMENT
If you have significant changes in procedures and/or organisms, please submit a new registration form. Please note that
authorizations expire two years from the original approval date.
Today’s date:
P.I.:
Lab Contact:
Department:
Renewal date:
Auth No.:
Email:
Email:
Building:
Phone:
Phone:
Room No.:
Is the project active? (If the answer is no, don’t continue filling out this form.)
Yes
No
Yes
No
Yes
No
Please enter the project’s title.
Animal care protocol # (If applicable.)
Are there any changes in project location? (If the answer is yes, please list the changes below.)
Add
Delete
Building Name and Room Number
Are there changes in the organisms/ biological materials? (If the answer is yes, please list the
changes below.)
Add
Delete
Organism
Biosafety Level
1
1
1
Infectious or potentially
infectious agent(s) and
toxin(s):
Strain # or Name
Concentration of
Toxin *
2
2
2
3
3
3
Source** –Commercial or Laboratory
(Name & Location)
*The concentration of toxins is limited by the Federal Government. Requests above those listed concentrations limits (web site) requires government
approval. **If the source of your biohazard agent is a non-commercial laboratory in the United States, you must contact Office of Technology
Innovation and Commercialization at ext. 7221 to obtain and sign a Material Transfer Agreement Form, MTA, for approval to be granted. Attach a
copy of the MTA to this application.
Are there changes in personnel? (If the answer is yes, please list the changes below.)
Add
Delete
Last Name
First Name, MI
NEU ID #
Yes
No
Appropriate Training Taken and Documented
Biosafety
Autoclave
Chemical
Hygiene 1 & 2
Is medical surveillance required?
Yes
No
Are there changes in laboratory procedures? (If the answer is yes, please summarize your request
for the amendment either in the space below or in an attachment.)
Yes
No
Last revised October 28, 2013
1
Biosafety Registration Form
AMENDMENT
PI’s signature:
Last revised October 28, 2013
Date:
2