Yale University
Cell Sorter Core Facility
Biosafety Questionnaire
The Yale Cell Sorter Facility is a multi-user facility where many different samples from
various sources that may contain known or unknown human pathogens are processed.
The safety of the staff and of users of the facility is of ultimate concern. Information
about the sample sources and potentially infectious agents is critical for effective
biosafety measures. To track and prepare for potentially infectious samples submitted to
the Cell Sorter Core this sample information form must be filled out completely. The
same biosafety questionnaire will be kept on file provided none of the information it
contains has changed. It is the responsibility of the Investigator to make sure that an upto-date questionnaire is on file. Failure to comply may result in a delayed or cancelled
sort. Appropriate biosafety approval of experiments prior to sample submission to the
core laboratory is required.
BSL-3 material can only be sorted on the LEPH FACS Aria, please contact Geoff
Lyon at geoffrey.lyon@yale.edu to arrange a BSL-3 Sort.
Date:_______________
Principal Investigator:_____________________
Investigator:____________________________
Phone:______________E-mail:___________________________
Laboratory Location:___________________________
Summary or description of project (provide details related to samples that will be sorted
and what will be done with the cells after sorting, limit to one paragraph).
1. Are you sorting human-derived, mouse-derived, or other material?(circle one)
If other material, please list.________________________________________
a) If mouse-derived, has the material been exposed to any known pathogens or
infectious materials? [_] Yes [_] No [_] Unknown
b) If from a mouse cell line, has the cell line been transformed with any of the
following viruses (EBV, herpes saimiri , adenovirus, retrovirus, lentivirus,
herpesvirus, etc.) [_] Yes [_] No [_] Unknown
c) If human-derived, or if mouse-derived but potentially infectious, has the
material been fixed adequately to kill infectious material?
[_] Yes [_] No [_] Unknown
If Yes, then what fixative and if fixed.
_________________________________________________________________
d) If live and infectious, what is the agent and the BSL level?
_________________________________________________________________
e) If live human-derived, is it patient-derived or from volunteer donors? (circle
one)
f) If live human-derived, has the donor been tested for any/all of the following
patogens: HIV, SIV, HepB, HepC, HepD, Herpesvirus simiae, LCMV, SARS,
Mycobacterium tuberculosis, Mycobacterium bovis or Neisseria meningitis?
g) If cell-line derived:
What was the method of transformation?
_________________________________________________________________
Are there or could there be any infectious particles released from the cells?
[_] Yes [_] No [_] Unknown
_________________________________________________________________
Signature
Date