3/28/2013 FOR IBC USE ONLY IBC # Date Approved Expiration

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FOR IBC USE ONLY
3/28/2013
IBC # _______________________
Date Approved ______________________
ASSURANCES AND SIGNATURES
Expiration Date ______________________
IBC Chair_____________________________________
Pursuant to applicable State and Federal laws and regulations and Texas Tech University policies and
procedures:

To the best of my knowledge, I affirm that all information contained herein is accurate and
complete.

I agree to comply with federal, state, and university requirements pertaining to handling, shipment,
transfer, and disposal of biological materials, to include annual lab inspections.

I agree to accept responsibility for the training of all personnel involved in this research and that all
personnel have been trained.

I understand that IBC approval of this protocol constitutes approval to work with the specified
agents (recombinant DNA, microorganisms, select agents, biological toxins, regulated and
particularly hazardous chemicals) using the specified biosafety procedures/practices and laboratory
facilities described herein.

I affirm that all personnel working on the project covered by this protocol have read and are in
compliance with the federal law defined in the USA Patriot Act.

I affirm that I am aware of and have read the NIH Guidelines for Research Involving Recombinant
DNA Molecules (NIH GUIDELINES).

I understand that all changes in agents, procedures/practices, and facilities must be reported in
writing to the IBC in the prescribed format, and that IBC approval shall be obtained prior to
implementation of these changes.

I understand that unauthorized use of recombinant DNA, microorganisms, select agents, biological
toxins, regulated and particularly hazardous chemicals or deviation from an approved IBC protocol
may result in suspension of research privileges and/or disciplinary action.

I understand that IBC approval is a prerequisite for obtaining IACUC approval for studies using live
vertebrate animals if recombinant DNA, microorganisms, select agents, and/or biological toxins are
involved.

I understand that IBC approval is a prerequisite for obtaining IRB approval for studies using human
subjects if recombinant DNA, microorganisms, select agents, and/or biological toxins are involved.

I understand that IBC approval does not confer approval to work with radioactive materials or
lasers.
Principal Investigator Name
Principal Investigator Signature
Date
Co-Responsible Faculty Name
Co-Responsible Faculty Signature
Date
Department Chair Name
Department Chair Signature
Date
Research Personnel Name
Research Personnel Signature
Date
Research Personnel Name
Research Personnel Signature
Date
Please send this form to the Office of Environmental Safety, MS 1090.
NOTE: If changes in information provided on this application occur, a revised signature form must be submitted.
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