Tissue Application Form (DOCX 33KB)

advertisement
APPLICATION TO USE FRESH OR FROZEN TISSUE (PLANT OR
ANIMAL) FROM AN IBC APPROVED PROJECT
FLINDERS INSTITUTIONAL BIOSAFETY COMMITTEE
Use this form to apply to use fresh or frozen tissue (plant or animal) from an IBC approved project.
If the tissue is required by a person who is external to Flinders University or Southern Adelaide Health Service
(FMC Site) a Material Transfer Agreement (MTA) should be submitted via the Research Services Office. Please
also ensure that ethics approval has been granted at the external institution.
Approval will NOT be granted to generate cell lines. If this is your intention, please submit an application to
the IBC for this dealing.
Researcher Details – Recipient of Tissue
Chief Investigator: Title & Name:
Contact details: University/School:
Discipline/Department/Section:
Email:
Phone:
Date application submitted:
IBC Approved Project Details – Supplier of Tissue
IBC Project Number:
Chief Investigator: Title & Name:
University/School:
Discipline/Department/Section:
Tissue Details
What is the origin of the tissue? : Plant
/ Animal
- Fresh
/ Frozen
Provide strain details:
Is the tissue pathogenic (e.g. secretes infectious agents)? : Yes
/ No
If yes, please give details:
Has the tissue been exposed to GM microorganisms?: Yes
/ No
If yes, please give details:
What is the intended use of the tissue?:
Will the tissue be used to generate cell lines?: Yes
/ No
Where will the research be conducted using the tissue? :
Where will the tissue be stored? :
As Chief Investigator it is my responsibility to ensure that:
Acknowledgement by Chief
Investigator
 All tissue will only be used for the purposes outlined above
 All tissue during transportation will be double contained &
Signature:
labelled
 All tissue will be disposed of in yellow bags & sent for
……………………………
incineration
Office Use Only: Approval
Signature IBC rep:
date:
** Please submit this application form to the IBC via email: [email protected]
Flinders IBC Tissue Application Form. Current as at April 2015.
Page 1 of 1
Download