REGISTRATION AMENDMENT Notice of Intent to Possess or Work with Recombinant DNA Molecules or Synthetic Nucleic Acid Molecules Institutional Biosafety Committee Georgia Institute of Technology Submit via email to: biosafety@gatech.edu http://www.researchintegrity.gatech.edu (This form is in Word and will expand to accommodate text). Principal Investigator PI Title Dept: Telephone Emergency Contact number: Email: Approved Project Title: Approval Number (e.g. R15001): Personnel If there are no changes from the approved protocol check here and skip to the next section Please note: you only need to modify the information that has changed from your approved protocol. Name all individuals who will be involved in this project or have access to the materials. 2 Title: Post-Doc, Graduate Student, Undergraduate, Staff, Other (Specify) Date of Completion of Training through EHS (Required) Details of Proposed Use If there are no changes from the approved protocol check here and skip to the next section Please note: you only need to modify the information that has changed from your approved registrationl. Source of Funding (Specify sponsor name, even if funding is pending) Project number or OSP Doc ID: If using departmental or foundation funds, so state. Is the proposed work or usage exempt from the NIH Guidelines for Research involving Recombinant DNA Molecules or Synthetic Nucleic Acid Molecules? Yes (Exempt) No (Non-Exempt) Level of containment required: In vitro: BSL-2 In vivo: ABSL-1 ABSL-2 Give the specific NIH citation to justify your determination of exemption or other level of containment: (e.g. Section III-D): NIH Guidelines can be viewed at: http://oba.od.nih.gov/rdna/nih_guidelines_oba.html Registration approvals will be withheld unless the NIH citation is provided. Brief, non-technical (lay) abstract of planned change or addition to existing protocol: Research Materials to be used: (Indicate binomial name and strain of the recombinant or synthetic DNA molecules to be used). For each experiment, provide the following: Georgia Institute of Technology Office of Research Integrity Assurance IBC@gatech.edu Amendment for IBC Registration: rDNA or SNA Molecules September 2015 Page 1 Source of the DNA (organisms): Nature of the inserted sequences: Vector Details: Please provide/attach Vector maps for each vector you will be using. Describe below the safety precautions for working with each vector, including whether it is self-inactivating, self-replicating, etc. List host cells, vectors, recombinant materials: (E. coli, K-12 system, Saccharomyces system, insect cells, plasmids, cosmids, phages, etc.). Please list any cell lines that will be used or modified (human or animal) providing the cell line and strain: 3 If there are no changes from the approved protocol check here and skip to the next section Are any of the following genes, viruses, factors, or conditions involved? Mark Yes or No Deliberate transfer of drug resistance into organisms that do not acquire them naturally? (except for approved host-vector systems that contain antibiotic resistance markers) Deliberate transfer of Recombinant DNA or Synthetic Nucleic Acid Molecules into humans? Genes that produce vertebrate toxins with LD50 less than 100 ng/kg of body weight? Using human or animal pathogens as host-vector systems? Human or animal pathogen DNA cloned into non-pathogenic prokaryote or lower eukaryote? Using infectious animal or plant DNA or RNA viruses in tissue culture or using defective viruses when a helper is present? Altering an animal genome by Recombinant DNA or Synthetic Nucleic Acid Molecules or testing viable modified microorganisms in whole animals? Genetic engineering of plants by Recombinant DNA or Synthetic Nucleic Acid Molecules methods or use of plants with microorganisms or insects containing rDNA? Experiments involving more than 10 liters of culture? 4 Deliberate release of Recombinant DNA or Synthetic Nucleic Acid Molecules modified plants or animals into the environment? Location If there are no changes from the approved protocol check here and skip to the next section Please note: you only need to modify the information that has changed from your approved protocol. Indicate where project will be conducted Building Room Telephone Georgia Institute of Technology Emory University Grady Hospital VA Medical Center Other (specify) 5 Containment and safety equipment If there are no changes from the approved protocol check here and skip to the next section Please note: you only need to modify the information that has changed from your approved protocol. Will a biological safety cabinet (BSC) be used? Georgia Institute of Technology Office of Research Integrity Assurance IBC@gatech.edu Yes No Type of BSC: Class II Amendment for IBC Registration: rDNA or SNA Molecules September 2015 Page 1 Manufacturer name: Date of last certification: A1 B1 A2 B2 Name of certifier: Will a horizontal or vertical laminar flow “clean bench” be used for the planned activity? Yes No Other safety equipment to be used: Method of decontamination of biological or infectious wastes: Safety pipettes Autoclave Centrifuge Incinerator Safety cups Chemical Disinfectant (Specify) Chemical fume hood Note: Bleach and Autoclaving may never be used in combination Others: As a result of this project, will there be any ultratoxic, shock sensitive or other chemicals which will require special handling during use, storage or disposal? Yes No If yes, provide details: Describe in detail the method of disposal of chemical or biological wastes: Have the safety precautions included in the Material Safety Data Sheets been incorporated into your procedures? Yes No Other boards or committees that must review and approve this proposed use: Submittal date Protocol number Pending Status Approved Chemical & Environmental Safety Committee Institutional Review Board Institutional Animal Care & Use Committee Radiation Safety Biological Materials Safeguards Committee You may also need to coordinate with the Biosafety Officer, the Responsible Official, and/or Environmental Health and Safety. Dual Use Research of Concern (DURC) Potential Assessment Despite its value and benefits, certain types of research conducted for legitimate purposes can be utilized for both benevolent and harmful purposes. Such research is called Dual Use Research (DUR). Dual Use Research of Concern (DURC) is a subset of DUR and is defined as “life sciences research that, based on current understanding, can be reasonably anticipated to provide knowledge, information, products, or technologies that could be directly misapplied to pose a significant threat with broad potential consequences to public health and safety, agricultural crops and other plants, animals, the environment, materiel, or national security.” On March 29, 2012, the U. S. Government (USG) released the USG Policy for Oversight of Life Sciences Dual Use Research of Concern to establish the requirements for the oversight of DURC by the USG. On September 24, 2014, the USG Policy for Institutional Oversight of Life Sciences Dual Use Research of Concern was released to establish the requirements for institutional (i.e., non-USG) oversight of DURC. The USG considers these two policies to be complementary. These definitions could potentially encompass a number of life sciences research projects at Georgia Tech, however, the current scope of the USG Policy has been limited to the following agents and toxins and categories of experiments. Research must involve both a listed agent/toxin and category of experiment to be deemed potential DURC. Agent or Toxin Involved in Project (check all that apply) Verify if this project directly involves non-attenuated forms of 1 or more of the 15 listed agents. Georgia Institute of Technology Office of Research Integrity Assurance IBC@gatech.edu Amendment for IBC Registration: rDNA or SNA Molecules September 2015 Page 1 Avian Influenza (highly pathogenic) Bacillus anthracis Botulinum neurotoxin (any quantity) Burkholderia mallei Burkholderia pseudomallei Ebola virus Foot-and-mouth disease virus Francisella tularensis Marburg virus Reconstructed 1918 influenza virus Rinderpest virus Toxin producing strains of Clostridium botulinum Variola major virus Variola minor virus Yersinia pestis NONE Experimental Effects (check all that apply) Indicate whether the research project indicated above produces, aims or can be reasonably anticipated to produce any of the following experimental effects. Enhances the harmful consequences of the agent or toxin. Disrupts the immunity or the effectiveness of an immunization against the agent or toxin without clinical or agricultural justification. Confers to the agent or toxin resistance to clinically or agriculturally useful prophylactic or therapeutic interventions against the agent or toxin or facilitates its ability to evade detection methodologies. Alters properties of the agent or toxin in a manner that would enhance its ability to be disseminated. Alters the host range or tropism of the agent or toxin. Enhances the susceptibility of a host population to the agent or toxin. Generates or reconstitutes an eradicated or extinct agent or toxin listed in Question 6.2 of this form. NONE If you checked any of the above experimental effects, please explain: 6 Previous Work Experience and Additional Information If there are no changes from the approved protocol check here and skip to the next section Please note: you only need to modify the information that has changed from your approved protocol. What is the new research team’s previous work experience with the agent/materials specified in this application? Please indicate any additional information or comments pertinent to the Institutional Biosafety Committee review: 7 Certifications and Signatures PI CERTIFICATION: I have read and am familiar with the standard and special microbiological practices, containment equipment, personal protective equipment, and laboratory facilities recommended for the biosafety level applicable to this project. I will ensure that all faculty, staff, and students working on this project will follow these recommendations as a condition of Institutional Biosafety Committee approval of this project. Date: Principal Investigator Signature _____________________(or submit via GIT email for electronic signature) DEPARTMENT CHAIR/GTRI LABORATORY DIRECTOR SIGNATURE: I have reviewed this DNA registration and related research plans and concur with their submission to the Institutional Biosafety Committee for review. Date: Department Head Signature _____________________(or submit via GIT email for electronic signature) Save this signed amendment form as a PDF file, and email it AND A COPY OF NEW GRANT PAGES to: biosafety@gatech.edu. In lieu of dept head signatures, the Office of Research Integrity Assurance will accept an email from the dept head, sent to biosafety@gatech.edu, in which the dept head states something like: “I have reviewed this rDNA registration and related research plans and concur with their submission Georgia Institute of Technology Office of Research Integrity Assurance IBC@gatech.edu Amendment for IBC Registration: rDNA or SNA Molecules September 2015 Page 1 to the Institutional Biosafety Committee for review.” Georgia Institute of Technology Office of Research Integrity Assurance IBC@gatech.edu Amendment for IBC Registration: rDNA or SNA Molecules September 2015 Page 1