University of Nebraska Medical Center
Biosafety Policies and Procedures
(Put on Letterhead)
IBC40- Form 2
UNMC Sender:
Sender’s Fax#:
Date: ________________
(Recipient will FAX a signed copy to UNMC sender prior to shipment)
ACCEPTANCE OF RESPONSIBILITY
For Material Associated with Certificate of Analysis #____________________
Standardized methods have been performed to determine the sterility of the requested material (see
Certificate of Analysis). The recipient acknowledges that the material requested from the University of
Nebraska Medical Center could potentially be pathogenic and may represent a hazard to public healt h.
The UNMC sender cannot guarantee sterility once the material has been offered for shipment.
Accordingly, the Requesting scientist and associated Facility agrees to:
 accept responsibility for the materials received;
 ensure that investigators who work with the material at the Requesting Facility are qualified through
education and training to work with such material in accordance with accepted safety standards;
 not transfer, export, resell, or otherwise dispose of any items received under this d ocument to any
third party without written authorization from the Sender;
 not permit access to the materials by foreign nationals when to do so would constitute a violation of
export control laws;
comply with all applicable laws and regulations pertaining to these materials or their handling, storage,
use, and transportation;
destroy all materials according to accepted practices for destruction of microbiological cultures or
reagents upon completion of work; and
 not hold the Board of Regents of the University of Nebraska, the University of Nebraska Medical
Center, or any other agencies within the University system responsible for the content or use of the
requested material, to the extent permitted by Federal law.
The undersigned certify that they are authorized to commit to this legally binding agreement.
Scientist (print name)
_________________________________
Authorized Institutional Official Signature
encl: Certificate of Analysis
____________________________________________
Signature
Date
____________________________________________
Requesting Facility Name and Address
University of Nebraska Medical Center
Biosafety Policies and Procedures
IBC40- Form 3
Examples of Avirulent Select Agents
___________________________________________________________
Yersinia pestis
Tjiwide S and CDC A1122
Bacillus anthracis
Sterne and Pasture
Brucella abortus
Strain 19 and RB51
Coxiella burnetii
Phase II, Nine Mile Strain
Francisella tularensis subspecies novicida
Utah 112 (ATCC 15482)
Francisella tularensis subspecies holartica
LVS
Francisella tularensis biovar tularensis
ATCC 6223