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.