Cover Page Form - Texas A&M University

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Texas A&M University-Kingsville

Institutional Biosafety Committee

Office of Research and Sponsored Programs: (361) 593-3344 or [email protected]

Biosafety Evaluation Cover Page Form

Principal Investigator

(Must be faculty or academic professional administrative staff.)

Name (Last name, First name MI):

Phone Number:

Mailing Address: Pager or Cell Phone Number:

Fax:

TAMUK Employee ID:

Occupational Position:

Faculty Staff

Note: Students cannot be Principal Investigator.

Email:

University Department:

Person preparing this document if different from above

(Last name, First name):

Project/Course Title:

Email Phone Number

Brief Summary of Goals and Activity. Use language that is understandable to those with a general knowledge of biology, and define all acronyms. (200 word limit):

Forms Submitted for IBC Review

Potential or Incidental Infectious Agent Exposure Form

rDNA Exempt Form

Recombinant DNA and Artificial Gene Transfer Form

Infectious Agent Usage Form

Biological Toxins Usage Form

Decontamination Plan Form Waste Disposal Plan Form

1. Project Identification

1.1 Type of Application: New Protocol 3-year Renewal of IBC #

(If this is a 3-year resubmission, do not use language referring to the previous protocol or grant in this form.)

Anticipated Start

Date:

2. Project Funding

Revised: 10/29/13

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2.1 Source of Funding

Please do not send grant applications to the IBC

Name of Sponsor:

Address:

Contact Person:

Grant number

(if available):

Type of Project

:

Grant:

Teaching

Unfunded research projects

Will be submitted

Submitted

Approved. The duration of grant approval: 5 years Other:

This application must be written for a maximum of three years only. IBC applications expire after 3 years, at which time a new application will be requested.

3. Activities involve the use of (check all that apply):

Human subjects

IRB protocol number:

Whole animals; Species:

Common Name of Species:

Pending

Approx. number:

IACUC protocol number: Pending

Does this project involve the creation of transgenic or knockout animals*?

No

Yes

*If you purchase transgenic or knockout animals from a non-University vendor, check “No”.

Does this project involve inoculation of animals?

No

Yes. Indicate the amount and route of administration:

Concentration or range of inoculation

:

Whole plants; Species:

In vitro work (cell culture):

Cells used in these experiments (check all that apply):

Human Cells

Non-human Primate Cells

Animal Cells

(non-primate)

Plant Cells

Insect Cells

Other:

Microorganisms; Species:

Fungi; Species:

Insects; Species:

Revised: 10/29/13

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4. Project Personnel and Training

4.1 Personnel conducting the experiments

List the personnel that will be working on this study below (including students and temporary staff). For each individual conducting the experiments, list their degree, applicable training, relevant experience (including duration) and their role in the project and indicate whether they should receive correspondence about the study from the IBC.

Please Note:

It is the responsibility of the Principal Investigator to log onto the CITI program at https://www.citiprogram.org/Default.asp

? or to log onto TrainTraq in Single Sign On at https://sso.tamus.edu/Logon.aspx?ReturnUrl=%2f and select the appropriate biosafety training courses for their personnel. These classes should be listed in the table below. At a minimum, the IBC requires that all personnel listed on an approved IBC protocol be required to take the CITI Basic Biosafety course.

Name

(Last Name, First

Name MI)

TAMUK

Employee or

Student ID

Role in

Project

Degree / Years of Experience with Protocol Procedures

Training Classes

Required by

Principal

Investigator

Date Training

Completed*

*Note: Successful completion of all training classes is required for IBC protocol approval. PI is responsible for ensuring all relevant training modules are completed for all personnel involved. A copy of the completed training module certificates for listed personnel should be submitted with the IBC protocol to the Research Compliance Liaison in the Office of Research and Sponsored Programs.

5. Assurance and Signature

Assurance by Principal Investigator

Submission of this form and associated forms confirms my agreement to perform all activities according to the

NIH

Guidelines for Research Involving Recombinant DNA Molecules

and use biosafety practices described in the

CDC/NIH Publication

Biosafety in Microbiological and Biomedical Laboratories (BMBL)

. This application accurately and completely reflects the activities described in any grant, contract, or non-funded research.

Additional conditions required by the Institutional Biosafety Committee on behalf of Texas A&M University-

Kingsville will also be followed.

Signature of Principal Investigator: Date:

You have reached the end of this form. Please make sure that you have responded to every question on this application (even if your response is “not applicable”). Please make sure that you have signed the assurance statement.

Submit to:

Research Compliance Liaison

Email as PDF to:

[email protected]

Mail Code:

MSC 201

Fax:

361-593-3409

Revised: 10/29/13

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