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