Institutional Biosafety 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 any of your biological materials is a non-commercial laboratory, you must contact the Office of Research Administration
and Finance at 617.373.5600 to obtain and sign a Material Transfer Agreement (MTA) form. In order to for approval to be granted, a copy of the MTA
must be attached to this registration form.
Are there changes in personnel? (If the answer is yes, please list the changes below.)
Add
Delete
Last Name
Is medical surveillance required?
Last revised October 28, 2013
First Name, MI
NEU ID #
Yes
No
Appropriate Training Taken and Documented
Biosafety
Autoclave
Chemical
Hygiene 1 & 2
Yes
No
1
Institutional Biosafety Form
AMENDMENT
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.)
PI’s signature:
Last revised October 28, 2013
Yes
No
Date:
2