Protocol Number (internal use only): B20___-___
BISHOP’S BIOHAZARDS APPLICATION FORM FOR RESEARCH OR
COURSE-BASED ACTIVITIES
Faculty should submit the Biohazards Application Form to the Research Office by email (PDF file
including the form, duly signed and dated, and the required appendices) to julie.fredette@ubishops.ca.
You can consult the Canadian Biosafety Standards and Guidelines for Research Involving Biohazardous
Materials at: http://canadianbiosafetystandards.collaboration.gc.ca/
It is mandatory to complete all sections. If a section does not apply, you must insert N/A. For student
research project, the supervisor must complete the form.
1. Principal Investigator
Name
Department
Division/School
Phone
Laboratory location
Email
☐ Bishop’s
☐ Other, specify
2. Co-investigator
Name
Department
Division/School
Phone
Email
2. Emergency (person(s) designated to handle emergencies)
Name
Phone (work)
Home/cellular
Name
Phone (work)
Home/cellular
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3. Research Project or Course-based activities
Please provide the experimental procedures to be used involving biohazards as an appendix.
A. Title of the Project or Course
B. Anticipated Start and End Dates of the Project or Course
Research work with biohazards MUST NOT begin before ACBC approval
Start date: Click here to enter a date.
End date: Click here to enter a date.
C. Funding Source
☐ Provincial (FRQSC, FRQNT, FRQS)
☐ Federal (NSERC, SSHRC, CIHR)
☐ Internal (Senate Research Committee)
☐ Other, specify:
☐ Does not apply
D. Human Participants and Animals Use
If the project imply human participants or animals the appropriate ethics form must be completed
and submitted to the Research Ethics Board or to the Animal Care and Biosafety Committee. Review
and approval by Bishop’s Research Ethics Board is necessary for human remains, cadavers, tissues,
biological fluids, etc., taken in routine situations but which are later used for educational and/or
research purposes.
1. Does the project involve human
participants?
2. Are animals used?
☐ Yes, please see REB procedures
☐ No
☐ Yes, please see ACBC procedures
☐ No
4. Type of Research (select one)
☐
☐
☐
☐
☐
Professor’s research
Course-based activity (research or teaching)
Honours thesis
Graduate research
Other, specify:
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5. List of User(s) (research personnel, co-applicants, lab technicians, lab assistants, employees,
interns)
List the name, position, and the biosafety background of user(s) who will handle biohazards.
Name
Position / Job title
Qualification &
Phone and email
Approved by H&S
training
Officer
(internal use only)
6. Biohazards (select all cases that apply)
Agents / Materials
Yes/No
(select)
Bacteria
No
Fungi / yeast
No
Virus
No
Parasite (life specimen)
No
Prions
No
Blood, body fluids
(saliva, urine)
No
Human tissues
No
Animal tissues
No
Toxins
No
Transformed cell
No
Primary cell cultures
No
Human cell lines
No
Proposed containment level
Risk Group
Choose a containment level
Choose a risk
group
Choose a risk
group
Choose a risk
group
Choose a risk
group
Choose a risk
group
Choose a risk
group
Choose a containment level
Choose a containment level
Choose a containment level
Choose a containment level
Choose a containment level
Choose a containment level
Choose a containment level
Choose a containment level
Choose a containment level
Choose a containment level
Choose a containment level
Source/
Supplier
Choose a risk
group
Choose a risk
group
Choose a risk
group
Choose a risk
group
Choose a risk
group
Choose a risk
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6. Biohazards (select all cases that apply)
Agents / Materials
Yes/No
(select)
Transgenic living being
No
Recombinant DNA or
RNA molecules
No
Proposed containment level
Choose a containment level
Choose a containment level
Risk Group
Source/
Supplier
group
Choose a risk
group
Choose a risk
group
7. Location of Project
Institution / Building
Room number Description of use
Shared space
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
8. Location of Biocontainment Cabinets
Institution / Building
Room number Model / serial number
Date of last certification
Click here to enter a date.
Click here to enter a date.
9. Biohazards Waste and Decontamination
A. Will this project produce biohazards waste?
☐ Yes
☐ No
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9. Biohazards Waste and Decontamination
B. Indicate for each specific type of biohazard, disposable contaminated materials, reusable
contaminated materials, and waste materials the protocol that will be used for waste and/or
decontamination.
Reusable materials include, but are not limited to, lab coats and glassware. Waste materials include,
but are not limited to, cultures (liquid, solid), parasites, transgenic living beings, disposable equipment
(pipet tips), and contaminated debris. If using steam sterilization, indicate time and temperature
cycles. If using disinfectant, indicate the name of the disinfectant and kill times.
If the project generates mixed waste, i.e. biohazards mixed with radioisotopes or hazardous materials,
indicate how this waste will be handled.
Type of Waste
Decontamination Protocol
☐ Incineration (biohazards waste boxes)
☐ Chemical disinfection
☐ Autoclave
☐ Other, specify:
☐ Incineration (biohazards waste boxes)
☐ Chemical disinfection
☐ Autoclave
☐ Other, specify:
☐ Incineration (biohazards waste boxes)
☐ Chemical disinfection
☐ Autoclave
☐ Other, specify:
☐ Incineration (biohazards waste boxes)
☐ Chemical disinfection
☐ Autoclave
☐ Other, specify:
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10. Safety Procedures
Address the risks and indicate the methods, procedures, and personal protective equipment that will be
used to prevent exposure and/or release of the materials.
Methods
Procedures
Protective equipment
☐ Gloves
☐ Lab coats
☐ Safety glasses
☐ Face masks
☐ Face shields
☐ Respirators
☐ Ear plugs
☐ Shoe covers
☐ Bonnets
☐ Gloves
☐ Lab coats
☐ Safety glasses
☐ Face masks
☐ Face shields
☐ Respirators
☐ Ear plugs
☐ Shoe covers
☐ Bonnets
☐ Gloves
☐ Lab coats
☐ Safety glasses
☐ Face masks
☐ Face shields
☐ Respirators
☐ Ear plugs
☐ Shoe covers
☐ Bonnets
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11. Emergency Response Plan
Describe your specific emergency response plan for work with biohazards
Accidental, incidental
and/or intentional
release
Loss of power
Needlestick / Medical
Fire
Building evacuation
Other
12. Transportation
A. Will this project involve transportation? (if applicable provide certificate(s) as an appendix)
On Site
Off Site
☐ Yes
☐ Yes
☐ No
☐ No
B. Indicate the methods, procedures, and personal protective equipment that will be used to prevent
exposure and/or release of the material.
Methods
Procedures
Protective equipment
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13. Experimental Procedures
Please indicate the experimental procedures to be used involving biohazards, including conditions for
collection, growth, and maintenance. Include how aerosols from blending, mixing, sonication, pipetting,
centrifugation, etc., will be controlled. If using sharps, explain why they must be used and how procedures
involving the use of sharps shall be conducted safely. Include procedures involving the use of plants,
animals and human participants.
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14. Attestation
I certify that the information provided in this submission form is accurate and that any changes to the
protocol will be submitted to the Animal Care and Biosafety Committee for approval prior to initiation.
I certify that I have read, become familiar with, and agree to abide by current, applicable guidelines and
regulations, including but not limited to, the Canadian Biosafety Standards and Guidelines, and the
Canadian Food Inspection Agency’s policies and guidelines, Bishop’s Laboratory Health and Safety
Procedures, and Bishop’s general policy with regards to occupational health and safety.
I agree to accept responsibility for the training of all laboratory and support personnel involved in this
project and personnel sharing space and/or equipment on potential biohazards, relevant biosafety
practices, techniques, emergency procedures, and incident reporting.
I will immediately report to the Security Office and to the Biology lab technician all incidents. I will
submit a written report concerning the incident to the Research Office julie.fredette@ubishops.ca
within 72 hours of the incident.
I will not transfer biohazards to another party without approval of the Animal Care and Biosafety
Committee.
I agree to comply with all conditions in the permit and that no work will be initiated prior to the project
approval by Bishop’s Animal Care and Biosafety Committee. I accept responsibility for the safe conduct
of the work and I will inform all personnel who may be at risk of exposure to biohazards of potential
hazards associated with the work.
Click here to enter a date.
Signature of Investigator
Date
Signature of Co-investigator
Click here to enter a date.
Date
Click here to enter a date.
Signature of Supervisor
(When applicable)
Date
Note: Unsigned and undated forms will not be reviewed by the Animal Care and Biosafety Committee.
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