University of Wisconsin Oshkosh
Office of Grants and Faculty Development
Institutional Biosafety Committee
RECOMBINANT DNA AND SYNTHETIC NUCLEIC ACID MOLECULES
PROTOCOL APPLICATION FOR NON-EXEMPT ACTIVITIES
IBC Use Only
Protocol Number:
Expiration Date:
Please submit one (1) hard copy of this form with required signatures to the Office of Grants and Faculty Development,
Dempsey Hall 214. You must also submit one (1) electronic copy to biosafety@uwosh.edu ALL individuals listed on this
application must provide a copy of their CITI completion report. Instructions for completing CITI training can be found on
the last page of this application. Your registration will not be processed until the signed hard copies and CITI training
documentation are received.
I. COVER PAGE: Project Identification, Personnel and Signatures
PROJECT TITLE:
Phone No:
PRINCIPAL INVESTIGATOR:
E-Mail:
Campus Mailing Address:
Funding Agency:
New Submission
Grant Identification Number (if federally funded):
Grant Renewal
Revision/Resubmission
Useful Resources:
Biosafety in Microbiological and Biomedical Laboratories (BMBL), 5th Edition
NIH Guidelines for Research Involving Recombinant or Synthetic Nucleic Acid Molecules
American Biological Safety Association (ABSA) Risk Group Database
American Type Culture Collection (ATCC)
PI Certification:
By signing below I am agreeing that all work on this project will maintain compliance with the NIH Guidelines for Research
Involving Recombinant or Synthetic Nucleic Acid Molecules. Additionally, these activities will be conducted using
biological safety practices described in the CDC/NIH publication titled “Biosafety in Microbiological and Biomedical
Laboratories” (BMBL) and by additional stipulations set forth by the University of Wisconsin Oshkosh Institutional
Biosafety Committee (IBC). If the IBC approves this application, I agree to execute this research as described; request
approval from the IBC for modifications; comply with the guidelines set forth by the IBC, and be responsible for the
training, supervision and work of my staff. I realize that failure to adhere to the policies related to this research may result
in suspension or revocation of permission to perform this research at UWO facilities.
Signature of PI:
Date:
Signature of Department Chair:
Date:
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II. Class Determination
A. Check the appropriate section(s) below to determine which class the proposed work would fall under. Please see
definitions for each section under Appendix A: “Definitions for Class Determination”
III-A.
Experiments that Require IBC Approval, RAC review, and NIH Director Approval before Initiation
http://www4.od.nih.gov/oba/rac/guidelines_02/NIH_Guidelines_Apr_02.htm#_Toc7261560
Deliberate transfer of drug resistance strain to microorganism that are unknown to acquire the trait naturally, if
such acquisition could compromise the use of the drug to control disease agents in humans, veterinary medicine
or agriculture.
III-B.
Experiments that require NIH/ORDA and IBC Approval before Initiation
http://www4.od.nih.gov/oba/rac/guidelines_02/NIH_Guidelines_Apr_02.htm#_Toc7261562
Experiments Involving the Cloning of Toxin Molecules with LD50 of Less than 100 Nanograms per Kilogram of
Body Weight.
III-C.
Experiments that Require IBC and IRB Approvals and NIH/ORDA Registration Before Initiation
http://www4.od.nih.gov/oba/rac/guidelines_02/NIH_Guidelines_Apr_02.htm#_Toc7261564
Experiments Involving the Deliberate Transfer of Recombinant DNA or DNA or RNA Derived from rDNA into one
or more Human Subjects.
III-D.
Experiments that Require IBC Approval before Initiation
http://www4.od.nih.gov/oba/rac/guidelines_02/NIH_Guidelines_Apr_02.htm#_Toc7261566
Experiments Using Risk Group 2, Risk Group 3, Risk Group 4 or Restricted Agents as Host-Vector Systems
Experiments in which DNA from Risk Group 2, Risk Group 3, Risk Group 4 or Restricted Agents is Cloned into
Nonpathogenic Prokaryotic or Lower Eukaryotic Host-Vector Systems.
Experiments Involving the Use of Infectious DNA or RNA viruses or Defective DNA or RNA Viruses in the
Presence of Helper Viruses in Tissue Culture Systems
Experiments Involving Whole Animals in Which the Animals Genome has been Altered by Stable Introduction of
rDNA into the Germ Line or Experiments Involving Viable rDNA-modified microorganisms tested on Animals
Experiments involving More than 10 Liters of Culture
III-E.
Research Experiments that Require IBC Registration Simultaneous with Initiation
http://www4.od.nih.gov/oba/rac/guidelines_02/NIH_Guidelines_Apr_02.htm#_Toc7261573
Experiments Involving the Formation of rDNA molecules Containing No More than Two-Thirds of the Genome of
Any Eukaryotic Virus.
Experiments Involving rDNA Modified Whole Plants and/or Experiments Involving rDNA Modified Organisms
Associated with Whole Plants.
Experiments Involving Transgenic Rodents (BSL1 containment only)
III-F.
Research Experiments that are Exempt from the NIH Guidelines.
http://www4.od.nih.gov/oba/rac/guidelines_02/NIH_Guidelines_Apr_02.htm#_Toc7261577
Experiments that are not in organisms or viruses (e.g., DNA sequencing, PCR)
Experiments that consist entirely of DNA segments from a single nonchromosomal or viral DNA source.
Experiments that consist entirely of DNA from a prokaryotic host including its indigenous plasmids or viruses
when propagated only in the host or when transferred to another host by well-established physiological means.
Experiments that consist entirely of DNA from a eukaryotic host including its chloroplasts, mitochondria, or
plasmids when propagated only in the host.
Experiments that consist entirely of DNA segments from different species that exchange DNA by known
physiological processes.
Experiments that don’t present a significant risk to health or the environment as determined by the NIH Director.
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III.
Research Personnel
A. Identify personnel conducting the experiments (including students). Specify degree, applicable CITI training
completion dates, and project responsibilities.
Name
Degree
Qualifications/Training
CITI Training
Completion Date
Project Responsibilities
Attach an additional sheet if more space is required.
B. Provide details on the type(s) of project-specific training all personnel listed in III.A. have received. Include hands-on
training, training via supervisor, workshops, training duration, number of years/months of experience, etc.
IV. Animal Use
Any use of animals for research, teaching or testing purposes must receive approval from the UW Oshkosh Institutional
Animal Care and Use Committee (IACUC) prior to Institutional Biosafety Committee (IBC) approval. The IACUC requires
that the researcher submit an IACUC Animal Use Application for approval of animal use. Contact iacuc@uwosh.edu for
more information. IACUC forms can be found at www.uwosh.edu/grants/forms. Please note that the IACUC holds 1-4
meetings per semester and requires the PI to submit protocol applications at minimum two weeks before the next
scheduled meeting. IACUC meeting dates can be found at: www.uwosh.edu/grants/iacuc-meeting-dates
A. Does the experiment involve the infection and/or use of animals?
Yes
No
B. List animal specie(s) to be used in the proposed work and explain how use of this particular specie(s) is scientifically
justified:
V.
Project Summary*
A. Provide a summary of the proposed teaching or research activity in such a way that a scientist in another field will
understand (layman’s terms). Include methodology that will be used in the project when working with Non-Exempt
recombinant or synthetic nucleic acid molecules, touching on: 1). Experimental design, 2). Goals and Purpose, 3).
Methods to be used, and 4). Outcomes to be measured.
*If working with animals you must first receive prior approval from the Institutional Animal Care and Use Committee (IACUC)
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VI.
Recombinant DNA Utilization
A. Provide information on the following:
1. Gene name (explain acronyms)
2. Gene source(s)
3. Nature of the insert or protein expressed (Toxin, marker train, virulence factor, DNA repair gene, oncogene,
transcription factor, etc.)
4. Construct Use (cloning for sequencing, PCR expression in a microbe, expression in organ/tissue/cell culture, etc.)
VII. Vector Description(s)
A. Provide information on the items listed below. Attach a construct map, if available, and indicate any regions that
increase the safety of this construct.
1. Gene Transfer Method (conjugation, liposome, viral infection, electroporation, CaPO4, polyplexes, etc.)
2. Vector Backbone Source (bacterial plasmid, cosmmid, phage, virus synthetic, etc.)
3. Vector Technical Name (Include commercial vendor, if applicable)
4. Risk Attenuation (Replication defective, helper-dependent, disarmed, K-12 derivative, restricted to prokaryotic
expression, etc.)
VIII.
Toxic Molecules
A. Do the DNA clones contain genes for the biosynthesis of toxic molecules lethal for vertebrates?
No
Yes
B. If ‘Yes”, Provide LD50 information below:
IX.
Source
A. Explain how the material(s) will be acquired:
Laboratory Stock
Off-campus Collection
Off-campus Researcher
Directly from animal/plant tissues
Other (describe):
B. Provide further explanation of source, if needed:
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X. Transportation
A. Will recombinant or synthetic nucleic acid molecules be transported between locations (i.e. between labs in the same
building, between different buildings on campus, between campus and satellite off-campus locations)? Guidelines for
appropriate transportation can be found in the BMBL, 5th Edition
No
Yes
B. If “Yes”, please explain transportation procedures:
XI. Storage and Security
A. Explain how the rDNA materials will be stored and maintained while at UW Oshkosh facilities. Include information on
security to ensure unauthorized people cannot access the rDNA materials:
Lyophilized
Chemical-fixation
Refrigerator (Provide location:
)
Freezer (Provide location:
)
Storage cabinet (Provide location:
)
Incubator (Provide location:
)
In vivo (Also complete Appendix A: “Animals”)
Other (describe):
B. Provide further explanation of storage conditions, if needed:
C. Will storage space(s) be secured and/or locked? Provide explanation including who will have access to the materials:
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XII. Disposal
A. Explain how rDNA materials are inactivated and disposed. If a chemical disinfectant is used, state the kind and
concentration:
XIII. Personal Protective Equipment
A. Please select the personal protective equipment (PPE) to be worn for the procedures described on this form.
Questions regarding PPE requirements should be directed to biosafety@uwosh.edu
Hand Protection
Examination gloves
Heat resistant gloves
Cold resistant gloves
Eye Protection
Safety glasses
Goggles
Face shield
Goggles + Face shield
Body
Laboratory coat (white)
Scrubs
Blue smock/coveralls
Tyvek body suit
Waterproof boots
Hair
Hair cover/hat
Respiratory
Guidance on respirator selection can be found at: http://www.cdc.gov/niosh/docs/2005-100/pdfs/2005100.pdf
N-95 mask
Air purifying respirator (half mask/particulate)
Air-supplied respirator
Other (Explain):
B. Provide additional information, if needed, on PPE use for the proposed work:
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XIV.
Safety Equipment
A. Select the cabinet class that meets your research needs, if applicable. See ‘Definitions’ list below for descriptions of
biosafety cabinet classes.
Biosafety Cabinet:
Will your work require use of a biosafety cabinet?
Yes
No
Cabinet Class:
I
II
Autoclave:
Will your work require use of an autoclave?
Yes
No
III
Model:
Autoclave Location:
Cabinet Location:
Certification Date**:
Other Equipment (Explain):
** Biosafety cabinets under regular use must be certified on an annual basis by experienced personnel or through a
contracted and licensed company.
Class I cabinets are ventilated for personnel protection and have an inward flow of air away from operator. Exhaust air is
filtered through a HEPA filter. Class II cabinets are ventilated for personnel and product protection having an open front
with inward air flow for personnel protection, and HEPA filtered mass recirculated air flor for product protection. Exhaust
air is filtered through a HEPA filter. Class III cabinets are closed-front ventilated cabinets with gas tight construction
which provide the highest level of personnel protection. The cabinet is fitted with arm-length rubber gloves and is
operated under negative pressure. All supply air is filtered through HEPA filters. Exhaust air is filtered through two
HEPA filters or one HEPA filter and one incinerator.
Emergency Preparedness
This section requests a summary of all emergency response plans that are in place for your laboratory or work space.
XV.
Emergency Contact Information
A. Provide emergency contact information for the following:
i. PI and Research Staff
ii. Program Staff
iii. Student Health Center, personal physician, physician familiar with the materials, Environmental Health and
Safety, biohazards disposal company, department, or contact, etc. as appropriate
XVI. Associated Health Risks
A. Describe the health risks, as applicable, associated with the biological materials you will use. Include information on
available treatments and their recommended use for persons handling or in the presence of these materials.
XVII. Potential Exposure Hazards
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A. Identify potential exposure hazards (e.g., aerosol generation when transferring, mixing, or centrifuging, accidental
inoculation, ingestion, use of needles/sharps, etc.). If rDNA or synthetic nucleic acids will be used in animals, be sure to
specify additional risks related to animal handling, husbandry or by-products
B. Explain the procedure for mitigation of an exposure were to occur. How will personnel health/safety be protected?
XVIII. Laboratory Acquired Infections
A. Identify potential hazards and risk for laboratory acquired infections (LAI)
XIX. Accidental Spill and Containment Breach Response Procedure
A. Provide a spill response and/or containment breach procedure, as applicable, that will be utilized in the event of a spill
or breach. What steps will be taken to ensure the spill or breach is contained?
XX. Violations to Safety Protocol
A. Explain what steps will be taken if personnel are found to be performing work out of compliance with established
laboratory safety protocols or procedures.
Please note that any incidents such as exposures, personal injury (needle stick), accidental spills, or containment breaches where
recombinant DNA or synthetic nucleic acid molecules are utilized must be reported to the Institutional Biosafety Committee within 24
hours by completing the IBC Incident Report form and e-mailing to biosafety@uwosh.edu
Instructions for CITI Training for Biosafety and Security Program (BSS):
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1. Enter the training at www.citiprogram.org
a.
Select: New Users Register Here
b.
Create your profile and affiliate with University of Wisconsin Oshkosh.
c.
You will be prompted by response driven questions that will determine what course and modules you will be
required to complete based on your role in the Biosafety and Security Program.
a.
Example: If you are a committee member and a faculty researcher on campus, answer the
questions according to both of your roles.
d.
The program will provide you with a customized list of courses to complete. The course list will appear on your
Main Menu page.
e.
You can enter the training by clicking on any of the courses listed in your Main Menu. Each course is compiled of
numerous modules. There is typically a short quiz after each module. You must complete the quizzes to earn
credit for the course.
2.
Training may take 1-3 hours to complete depending on your role(s) in the program, so please plan accordingly.
3.
At the completion of the training, a completion report is issued verifying the curriculum completed. A hard copy of
the Training Certificate must be attached to the protocol application or registration form that you submit to the
IBC.
4.
The CITI Program training is valid for three (3) years. A refresher course will be required at the time of expiration
for continuing projects.
5.
For more information or questions about the CITI training requirement, please contact:
IBC Administration: biosafety@uwosh.edu
FOR IBC USE ONLY:
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Reviewer Recommendations:
Approval
Approve as submitted
Require Revisions
Modifications deemed to be minor in nature can be reviewed
through expedited review by the IBC Chair or his/her designee(s)
Significant Modifications will be reviewed by the Full
Committee at a convened meeting
Table
Table ( Ex: IBC needs additional information from PI in order to
make a determination, did not have time to review, need
additional expertise, or loss of quorum)
Disapproval
Unable to meet requirements for approval under NIH
Guidelines. (Ex: Risks significantly outweigh benefits or value of
the knowledge to be gained OR there are significant ethical
concerns)
Risk Group and Biosafety Level Determination
Risk group determined by convened IBC:
Risk Group 1 (RG 1)
Risk Group 2 (RG 2)
Risk Group 3 (RG 3)
Risk Group 4 (RG 4)
Biosafety Containment Level determined
Biosafety Containment Level 1 (BSL 1)
by convened IBC:
Biosafety Containment Level 2 (BSL 2)
Biosafety Containment Level 3 (BSL 3)
Biosafety Containment Level 4 (BSL 4)
IBC Approval Date:
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Appendix A: Definitions for Class Determination
III-A:
Definitions
Experiments that Require IBC Approval, RAC Review, and NIH Director Approval Prior to Initiation
(See page 16 of NIH Guidelines)
III-B:
Experiments that Require NIH/OBA and IBC Approval Prior to Initiation (See page 16 of NIH Guidelines)
Explanation: Experiments in this category cannot be initiated without submission of relevant information on the proposed experiment to
NIH/OBA. The containment conditions for such experiments will be determined by NIH/OBA in consultation with ad hoc experts. Such
experiments require IBC approval before initiation. Deliberate formation of recombinant or synthetic nucleic acid molecules containing
genes for the biosynthesis of toxin molecules lethal for vertebrates at an LD50 of less than 100 nanograms per kilogram body weight (e.g.,
microbial toxins such as the botulinum toxins, tetanus toxin, diphtheria toxin, and Shigella dysenteriae neurotoxin). Specific approval has been
given for the cloning in Escherichia coli K-12 of DNA containing genes coding for the biosynthesis of toxic molecules which are lethal to
vertebrates at 100 nanograms to 100 micrograms per kilogram body weight.
III-C:
Experiments that Require IBC and Institutional Review Board (IRB) Approvals and RAC Review Before
Research Participant Enrollment (See page 17 of NIH Guidelines)
Explanation: Human gene transfer is the deliberate transfer into human research participants of either:
1. Recombinant nucleic acid molecules, or DNA or RNA derived from recombinant nucleic acid molecules, or
2. Synthetic nucleic acid molecules, or DNA or RNA derived from synthetic nucleic acid molecules that meet any one of the following criteria:
a. Contain more than 100 nucleotides; or
b. Possess biological properties that enable integration into the genome; or
c. Have the potential to replicate in a cell; or
d. Can be translated or transcribed
III-D:
Experiments that Require IBC Approval Before Initiation (See page 18 of NIH Guidelines)
Prior to the initiation of an experiment in this category, the PI must submit a registration document to the IBC which contains
the following information: (i) the source(s) of DNA; (ii) the nature of the inserted DNA sequences; (iii) the host(s) and vector(s)
to be used; (iv) if tan attempt will be made to obtain expression of a foreign gene, and if so, indicate the protein that will be
produced; and (v) the containment conditions that will be implemented as specified in the NIH Guidelines. The Risk Group
(RG1-4) of the work will define the containment level (BSL 1-4).
III-E:
Experiments that Require IBC Notice Simultaneous with Initiation (See page 22 of NIH Guidelines)
All such experiments not listed in the above categories are considered part of this class. All such experiments may be
conducted at BSL-1 containment. A registration document shall be dated and signed by the PI and filed with the Institutional
Biosafety Committee at the time the experiments is initiated. The IBC reviews and approves all such proposals but IBC review
and approval prior to initiation of the experiment is not required
III-F:
Exempt Experiments (See page 23 of NIH Guidelines)
These experiments are exempt from the NIH Guidelines. A registration document must be completed by the PI and submitted
to the IBC office at the time the experiment is initiated. The IBC reviews and approves all such proposals but approval prior to
initiation of the experiment is not required.
.
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