POAP Appendix 2 (rev 9-08) Use of Substances Potentially Hazardous to Humans- Protection of Humans Materials considered hazardous include, but are not limited to, any of the following categories: I. Biological materials Bacteria, viruses, parasites, prions, oncogenic material or other potentially infectious materials Human blood, human body fluids, human tissues, normal or tumor cells lines derived from humans. Note. PI is responsible for ensuring employees working with above have been offered the Hepatitis B vaccine and obtain annual (BBP) Bloodborne Pathogen training. Recombinant DNA constructs Chemicals (including pharmaceuticals) that are carcinogenic, mutagenic, teratogenic or extremely toxic (a compound is considered highly toxic if it has an LD50 as a single oral dose for rats of < 1 mg/kg.) Investigational compounds whose toxicity has not been characterized. Non-standard anesthetics (i.e., urethane) Radiation radioisotopes irradiation X-ray Lasers This protocol involves the administration or treatment of biological materials to live animals. YES , NO If yes, answer questions below and complete Section II. A. A. List the bacteria, viruses, parasites, prions, oncogenic material or other potentially infectious materials: Name: Name: Name: Name: B. Will human blood, tissue, cells, body fluids or established cell lines be administered in live animals? YES , NO , If yes, please describe: C. Will any tumor cell lines be administered to live animals? YES , NO If yes, list name(s), designation(s), species, etc., of cell line(s): D. Do animal handlers require vaccination prior to experimentation? YES , NO , If yes, explain: E. Recombinant DNA Do you use or generate recombinant DNA? Yes , NO . Note: If the recombinant DNA is generated by the University of Pennsylvania Medical Genetics Vector Core Laboratory, the Vector Core Laboratory will register the recombinant DNA with the Institutional Biosafety Committee prior to generation and distribution. Registration by the Principal Investigator is not required. POAP Appendix 2 (rev 9-08) Please contact Dr. Abigail Smith, Associate Director for Diagnostic Services prior to final approval at abigail4@pobox.upenn.edu or call (215) 898- 4008. Complete the following table for all rDNA constructs used in this protocol: Construct Name Generated in your lab (give IBC #) Generated by PENN’s Medical Genetics Vector Core Lab (give IBC #) Gifted (give collaborator’s name/institution) Purchased (give company name) Recombinant DNA guidelines, the University’s recombinant DNA registration document, and the form to request exemption from the NIH Guidelines are available at the EHRS website (http://www.ehrs.upenn.edu/protocols/rDNA.html). It is your responsibility to renew your recombinant DNA IBC registration every three years. II. This protocol involves the administration or treatment of hazardous chemicals, toxins, anesthetics and/or drugs to live animals. The potential risk to persons (not animals) must be evaluated. If there is a risk posed through contact with the animals, their excreta or their bedding, describe the risk(s) in question IIB and include an explanation on how the risk will be controlled. YES , NO If yes, complete the chart and answer questions below. A. Complete the chart below for all chemicals (including toxins),,anesthetics or other drugs used in this protocol. This includes use of chemicals used in perfusions, such as paraformaldehyde. Substance Dose Route of Administration Poses a hazard through direct or indirect contact with the animal, its excreta or its bedding. (answer yes or no; do not leave blank) Yes Yes Yes Yes Yes No No No No No B. Describe how the hazard(s) listed above will be controlled whose use poses a hazard to humans. C. Anesthetic gases will be scavenged using one of the following methods: Active scavenging with a vacuum system Filtering with charcoal canister Used in a fume hood or a Class II type B biosafety cabinet Other (describe): POAP Appendix 2 (rev 9-08) D. III. Animal will be perfused in the following location: This protocol involves the administration or treatment of live animals with radioisotopes, irradiation, or X-rays? YES , NO . If yes, answer the appropriate questions below. A. Radioisotopes: YES , NO If radioisotopes are used, a radiation Protocol Summary Form must also be submitted to EHRS (may be submitted electronically). Please see: http://www.ehrs.upenn.edu/programs/radiation/licensing.html. Isotope(s): Licensee Name: Activity administered per animal: Where will radioisotope administration occur? Bldg: Rm.#: Will animal(s) be returned to the ULAR facility after isotope administration? YES , NO . IV. B. Irradiator Use: YES , NO Irradiator Licensee: Location of Irradiator: Name of User(s): C. X-Ray: YES , NO If yes, location: Will you be using a laser (other than a confocal microscope) in this protocol? YES NO , If yes please answer questions below. A. B. C. D. E. Manufacturer: Model: Wavelength: Maximum power output: Fiber delivery system? Yes , No