Laboratory Biosafety Training Program
BSL2/ABSL2 Registration Form
UTMB EMPLOYEES
Please complete and return to: Sharon Walters (x-28461)
General Information
Refresher:
Training level requested:
Yes
No
BSL2 (In vitro)
ABSL2 (In vivo/Animal)
For ABSL2 training only:


IACUC Protocol #: __________
Have you been cleared by Employee Health?
Yes
No
Yes
Yes
No
No
(If not, your training may be delayed until you have done so.)


Animal experience?
GNL ABSL2 Facility (complete ABSL2-Form 1)
Trainee Information
First Name:
Last Name:
UTMB ID Number:
Email:
Current Degree:
Position:
Department:
Route Number:
Phone Number:
After hour number:
Principal Investigator Information:
First Name:
Last Name:
Degree:
Position:
Route Number:
Phone Number:
UTMB ID Number:
Email:
List all agents to be used after training (do not leave blank):
Risk Group 2 agents:
Animal Risk Group 2agents:
Personal Protective Equipment to be used after training:
Surgical mask
Gown
Coverall
Head cover
2 pairs of cover shoes
Eye protection, specify:
2 pairs of gloves
Biosafety cabinet
Other, please specify:
For ABSL2 Training:
What species will you be working with on your approved protocol?
Mouse
G. Pig
Rat
Rabbit
Hamster
Ferret
Other:
What techniques will you be performing on your approved protocol?
Injections:
Bleeds:
Techniques:
Anesthesia Inhalational
Injectable
Euthanasia Cervical dislocation
CO2
Injectable
Necropsy w/ tissue collection
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Trainee Background Information
I. In-vitro Background
A. Previous experience working with Risk Group 1 agent
UTMB - Specify Name of PI:
Non-UTMB - specify which institute, lab and PI:
How many years of work:
B. Previous experience working with Risk Group 2 agents
UTMB - Specify Name of PI:
Non-UTMB - specify which institute, lab and PI:
How many years of work:
C. Previous experience working with Risk Group 3 agents
UTMB - Specify Name of PI:
Non-UTMB - specify which institute, lab and PI:
How many years of work:
List all infectious agents that you have used (must be completed):
Risk Group 1 agents:
Risk Group 2 agents:
Risk Group 3 agents:
List the different techniques previously used with listed agents (must be completed):
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II. For ABSL2 Training Only (Please check the appropriate boxes.)
What biosafety level do you have experience in?
ABSL1
ABSL3
ABSL2
ABSL4
What species do you have experience working with?
Mouse
G. Pig
Rat
Rabbit
Hamster
Ferret
Other:
What techniques do you have experience with?
Injections:
SQ
IM
ID
Gavage
IP
IV
Bleeds:
RO
IN
Submandibular
Saphenous
Cardiac Puncture
Other:
Techniques:
Anesthesia Inhalational
Injectable
Euthanasia Cervical dislocation
CO2
Injectable
Necropsy w/ tissue collection
List all infectious agents that you have used (must be completed):
Risk Group 1 agents:
Risk Group 2 agents:
If you will be working in the GNL after ABSL2 training,
please print and complete the ABSL2 – Form 1 through Section A (next page).
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GNL ABSL2 - FORM 1
GNL ABSL2 Facility Request for Training/Approval to Request Independent Access
Name (Print): _____________________________________
Inexperienced ABSL2 user
A.
Principal Investigator: ______________________________________
Experienced non-UTMB ABSL2 user
Experienced UTMB ABSL2 user
(Skip to section B)
New Users will receive documented training at a minimum of:
a.
20 hours (inexperience only)
b.
10 hours (previous experience in a non-UTMB ABSL2 facility, documentation must be provided)
All training must be provided by a direct supervisor or by an established ABSL2 laboratorian in their research group before he/she will be eligible for
independent access to the facility. During the training period, the experienced ABSL2 laboratorian must accompany the new user at all times while
in the facility.
c.
Name of Mentor(s), up to 3: ______________________________________________________________________________
d.
I understand these rules and will work only under the supervision of my mentor(s)
_______________________________________
___________
Signature of new user of the ABSL2 Facility
e.
MM / DD / YY
I understand the rules of the provisional training and will supervise and train the above user during his/her provisional access period.
_________________________
________________________
Signature of mentor(s)
Signature of mentor(s)
______________________
Signature of mentor(s)
_______________________________________
MM / DD / YY
___________
Signature of Principal Investigator
B.
___________
MM / DD / YY
BEFORE initiating mentorship in the ABSL2 facility the laboratorian must:


Read “GNL Building ABSL2 Biosafety Manual and Facility Standard Operating Procedures”
Attend the EHS ABSL2 training and ARC orientation of the ABSL2 Facility
a.
EHS ABSL2 Training
Completed: ________________________
Signature of EHS Representative
b.
ARC Training and Orientation
Completed: ________________________
Signature of ABSL2 ARC Representative
c.
Meet with ABSL2 Scientific Director
Completed: ________________________
Signature of Facility Director, ABSL2
___/___/___
MM / DD / YY
___/___/___
MM / DD / YY
___/___/___
MM / DD / YY
Once all signatures in Section B have been obtained mentorship in the facility may commence
C.
Approved to Submit Request for Independent Access:
_______________________________________
Signature of Principal Investigator
_______________________________________
Signature of Director, ABSL2
D.
___/___/___
MM / DD / YY
___/___/___
MM / DD / YY
Request GNL ABSL2 badge and pin code access through the website: www.utmb.edu/gnl/about/access.shtml
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