UNIVERSITY OF TEXAS MEDICAL BRANCH
NOTIFICATION OF USE
HUMAN AND NON HUMAN PRIMATE PRODUCTS
PRINCIPAL INVESTIGATOR:
DEPARTMENT:
OFFICE BUILDING/ROOM NUMBER:
LAB BUILDING/ROOM NUMBER:
ROUTE:
1. Purpose:
Clinical Lab
2. Type of submission:
New
3. Type of products used:
Human
Tissue, bone
IRB Approval #:
Blood, serum, body fluids IRB Approval #:
Primary:
Cell Cultures
Established:
Commercial:
EXT:
Research Lab
Renewal
Amendment (NOU #:
Non Human Primate
IACUC Approval #:
IACUC Approval #:
)
4. Concise description of work performed (include specific techniques used):
5. Biological Safety Level:
BSL2
BSL3
BSL3E
BSL4
6. In addition to eye protection, check the personal protective equipment (PPE) worn when handling
agent(s) in vitro:
Lab coat/gloves/eye protection (BSL2)
Cover gown/gloves/eye protection (BSL3)
Scrubs/cover gown/ gloves (BSL3E)
Positive pressure suits (BSL4)
Face Shield
Other specify:
Surgical mask
N95 respirator
Full/half-face respirator
PAPR
7. Check lab equipment used when handling agent(s) in vitro:
Centrifuge, type:
Blender
Homogenizer, type:
Sonicator
Shaker
Chemical Fume Hood:
Biological Safety Cabinet:
Other specify:
Building/Room:
Building/Room:
Building/Room:
Building/Room:
8. Method for disposal of biohazardous waste:
Placed in red bag for disposal.
Autoclaved, then placed in regular trash.
Chemically disinfected, then placed in regular trash.
Placed in yellow bag for incineration.
Chemical disinfection or autoclave of bulk liquid, then poured down sanitary drain or BSL3E/BSL4 effluent
treatment system.
Autoclaved, then packaged for incineration.
Other:
Revised: 10/20/2015
9. List disinfectant(s) used for surface decontamination and spills:
Cavicide
MicroChem
%
Bleach
%
Other
%
10. Complete the personnel experience table at the following link: Personnel Experience Table
Attached
11. Have personnel completed the online Standard Precautions training?
Yes
No
Please attach Standard Precautions certificates for all personnel. Online Bloodborne pathogen training is
required to be completed every two years for non-select agent users and every year for select agent users.
__________________________________________
PI Signature
Date
Institutional Biosafety Committee Use Only
_______________
Date Approved
_______________
Date for Resubmission
___________________________________
Chairman Signature
Revised: 10/20/2015
________________
NOU Number
______________________________________
Print Name