Texas Tech University Health Sciences Center
Institutional Biosafety Committee (IBC)
ANNUAL STATUS REPORT
1. Protocol Number:
2. Principal Investigator:
3. Title:
4. Campus:
5. Department:
6. Office room number:
7. Phone (Office):
8. FAX:
9. E-mail:
(Laboratory):
Submit your completed form to IBC.Submissions@ttuhsc.edu.
PLEASE CHECK THE APPLICABLE STATEMENT BELOW:
I request continuation without change of agents or room number (complete Section I)
I request continuation with changes in agents or room numbers (complete Section II)
I request termination of my protocol (complete Section III)
And complete ALL of the questions in the selected section.
SECTION I: NO CHANGES
1. List agents currently registered on my protocol. (please review your posted TTUHSC Biohazardous Material
and Research Laboratory License for the agents you currently have registered)
Biologicals:
Chemicals:
Do you plan to ship any hazardous chemicals or biological materials to other users? Yes
No
If you answered “Yes” please contact Safety Services for information on training requirements. Any
person who is involved in any way with putting hazardous materials into commerce is considered a hazmat
shipper according to 49CFR, and must be accordingly trained. If you are unsure of the requirements of
this law, please contact Safety Services for more information. 806-743-2597
Name of trained shipper:
2. List personnel currently working in your laboratory: (please copy lines for additional personnel)
Name
Position/title
Training Date for LSE*
*Laboratory Safety Essentials
2b. List any constraints on personnel (e.g., “only PI and John Doe may work with Shigella isolates”):
2c. DELETE the following personnel from my IBC protocol (simply list all deletions by name):
Signature of PI
Date
In the space provided, type your name and the date to certify the above information is accurate.
DATE APPROVED:
by:
NEXT REVIEW DUE:
APPLICATION RENEWAL DUE:
TTUHSC Institutional Biosafety Committee (IBC)
Page 1 of 3
http://www.ttuhsc.edu/admin/safety/
http://www.ttuhsc.edu/sponsoredprograms/ibc/
Rev. 04/30/14
IBC Protocol ASR
SECTION II: CONTINUE WITH CHANGES
1. Add or delete agents: List agents currently registered on your protocol. Indicate any agent(s) to be deleted by
writing (DELETE) following the agent name, and any agent(s) to be added by indicating (NEW) following the
agent name. (please review your posted TTUHSC Biohazardous Material and Research Laboratory License for the
agents you currently have registered)
Biologicals:
Chemicals:
Attach a completed Addendum A form for each biological hazard to be added and/or a completed Addendum B form for each
chemical. Forms can be found at the Safety Services Website.
Request disposal of chemicals through Safety Services website,
Please indicate how the biological agents were disposed:
Do you plan to ship any hazardous chemicals or biological materials to other users? Yes
No
If you answered “Yes” please contact Safety Services for information on training requirements. Any
person who is involved in any way with putting hazardous materials into commerce is considered a hazmat
shipper according to 49CFR, and must be accordingly trained. If you are unsure of the requirements of
this law, please contact Safety Services for more information. 806-743-2597
Name of trained shipper:
2. List personnel currently working in your laboratory: (please copy lines for additional personnel)
Name
Position/title
Training Date for LSE*
*Laboratory Safety Essentials
2b. List any constraints on personnel (e.g., “only PI and John Doe may work with Shigella isolates”):
2c. DELETE the following personnel from my IBC protocol (simply list all deletions by name):
3a. ADD the following room numbers to my IBC protocol:
3b. DELETE the following room numbers from my IBC protocol:
Signature of PI
Date
In the space provided, type your name and the date to certify the above information is accurate.
DATE APPROVED:
by:
NEXT REVIEW DUE:
APPLICATION RENEWAL DUE:
TTUHSC Institutional Biosafety Committee (IBC)
Page 2 of 3
http://www.ttuhsc.edu/admin/safety/
http://www.ttuhsc.edu/sponsoredprograms/ibc/
Rev. 04/30/14
IBC Protocol ASR
SECTION III: TERMINATION
1. Will you be retaining your laboratory?
Yes
No (If NO, skip to question 3.)
If YES,
2. List personnel currently working in your laboratory: (please copy lines for additional personnel)
Name
Position/title
Training Date for LSE*
*Laboratory Safety Essentials
2b. List any constraints on personnel (e.g., “only PI and John Doe may work with Shigella isolates”):
2c. DELETE the following personnel from my IBC protocol (simply list all deletions by name):
If NO,
3. Request disposal of chemicals through Safety Services website.
4. Please indicate how the biological agents were disposed:
5. If you are leaving TTUHSC, please follow TTUHSC OP 73.10 Faculty Laboratory Space Check-out
Procedures and complete the check-out check list. Contact Safety Services for assistance with laboratory
checkout procedures and for check-list approval.
Signature of PI
Date
In the space provided, type your name and the date to certify the above information is accurate.
DATE Termination Acknowledged by TTUHSC Institutional Biosafety Committee: ____
by:
__
__
Page 3 of 3
http://www.ttuhsc.edu/admin/safety/
http://www.ttuhsc.edu/sponsoredprograms/ibc/
Rev. 04/30/14