Office Use Only – IBC Reference #: …………………..
MICROBIOLOGICAL APPLICATION FORM
FLINDERS INSTITUTIONAL BIOSAFETY COMMITTEE
Use this form to apply for approval to use risk group 2 or higher microorganisms for teaching or
research purposes. Please refer to AS/NZ 2243.3:2010 Safety in Laboratories Part 3: Microbiological
Safety & Containment for more information regarding risk groups. This standard is available via the SAI
Global Website: http://www.saiglobal.com/online/autologin.asp
1: Chief Investigator’s Details (for student projects, the Chief Investigator should be the supervisor of the project)
Name:
Discipline/Department/School:
Email:
Phone:
Are you employed by Flinders University?
☐Yes
☐No
If no, who are you employed by, and what is your affiliation with Flinders University?
2: Contact Person for this Application (if different to above)
Name:
Discipline/Department/School:
Email:
Phone:
3: Project Information
Project Title:
Please select the appropriate option(s) to describe the proposed work:
☐
Handling clinical or environmental samples that are known to contain Risk Group 2 or
higher microorganisms (excluding performing routine diagnostic reporting)
☐
Isolation, enrichment or culture of unknown microorganisms from clinical or environmental
samples that are likely to contain Risk Group 2 or higher microorganisms
☐
Isolation or culture of a known Risk Group 2 microorganism
☐
Work involving Risk Group 3 or 4 microorganisms - please contact ibcadmin@flinders.edu.au
before submitting an application
☐
Work involving Security Sensitive Biological Agents - please contact ibcadmin@flinders.edu.au
before submitting an application
☐
Other - please contact ibcadmin@flinders.edu.au before submitting an application
Flinders IBC Microbiological Application Form. Last revised September 2015.
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Lay Summary: to be written in simple, understandable language
4: Description of Microbiological Work
Microorganism(s): If unknown, please give indication of expected species
Strain(s):
Characteristics:
Source(s):
Reference(s): where applicable
Description of work: please provide a brief overview of the microbiological work to be
conducted (e.g. culture methods, handling, transport, and disposal information, etc.).
5: Facility Details
List details of Physical Containment facilities where work is to be conducted.
If you require assistance with certification of a PC2 facility, please contact
ibcadmin@flinders.edu.au
Building(s)
Room number(s)
Flinders IBC Microbiological Application Form. Last revised September 2015.
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Access to other facilities: Please list any other common service facilities (e.g. Flinders
Microscopy Suite or Flow Cytometry Unit) in which non-fixed microorganisms are likely to be
handled, and attach a signed letter of approval or email from the facility manager.
6: Storage Information
Please list the storage location for any microorganisms associated with this project:
Building(s)
Room number(s)
Location
(e.g. locked -80 freezer)
7: Personnel & Training
Please provide brief details of the Chief Investigator’s relevant experience with Risk
Group 2 or higher microorganisms:
Please list all staff and students who will be working on this project, and complete
details of their biosafety training.
Have read Have Received a Biosafety Training Certificate
Biosafety
At
At another institution
Manual
Flinders
Name
(Y / N)
Year
Year
If yes, where?
NOTE: It is the supervisor’s responsibility to ensure that all students and staff involved in
the project attend Biosafety Training Day and are familiar with the contents of the Biosafety
Manual.
Flinders IBC Microbiological Application Form. Last revised September 2015.
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8: Risk Assessment
Please complete a WHS Risk Assessment for the project using the form available on the
Flinders Biosafety Website and addressing the hazards of:
 working with high-risk microorganisms
 unintentional release from containment
 transport, storage and disposal of high-risk microorganisms
Retain the original copy with your area’s WHS records, and submit a signed copy with this
application.
9: Authorisation
As Head of the Discipline/ Department/ School where this research is to be conducted, I
acknowledge that I am aware of this project being conducted in the Discipline/ Department/
School’s facilities:
Name:
Signature:
Date:
As the Chief Investigator for this application, I acknowledge that the information provided is
true and correct and that I am aware of my responsibilities with regards to biosafety at Flinders
University:
Name:
Signature:
Date:
** Please submit this application form, together with the Risk Assessment and any
supporting documentation to the IBC via email: ibcadmin@flinders.edu.au
Please retain a copy of the completed application for your own records.
Flinders IBC Microbiological Application Form. Last revised September 2015.
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