Office of Regulatory Compliance & Safety 2013 Mississippi State University Institutional Biosafety Committee Application Update/Modification/Completion Form If you have changes in: personnel, laboratory location, experimental methods, biohazardous materials, or facility containment level please submit this form. The form will be reviewed by the IBC Chair and BSO to determine if the changes are significant enough to warrant a new IBC application. A modification must be approved by the IBC prior to initiation of the modified protocol. IBC Application Number: Principal Investigator: This form is being used for: □ Annual update with no project changes (Complete page 1 only). □ Modification to ongoing project □ Annual update with modification □ Completed Project (Complete page 1 only). I certify that the information provided in this form is complete and accurate and consistent with any proposal(s) submitted to external funding agencies. I agree that modifications to the originally approved project will not take place without prior review and approval by the IBC, and that all activities will be performed in accordance with all applicable federal, state, local and Mississippi State University policies. I will follow applicable biosafety level requirements; comply with all shipping requirements and waste management practices. I will ensure that all personnel have appropriate training including but not limited to: biosafety principles and techniques, accidental spill response, and proper handling of biohazardous materials and waste management. I am aware that the IBC reserves the right to conduct inspections of the research facilities at any time. Signature of Principal Investigator Date Approved by IBC Chair Date Approved by BSO Date Office of Regulatory Compliance & Safety 2013 PROPOSED CHANGES Please answer yes or no for each question. Detail any changes from the previously approved project. Please provide sufficient detail for each change to allow the IBC to make an adequate review. 1. Change In Location Add Delete □ □ □ □ □ □ □ □ Yes 2. Personnel Changes Yes Add Delete □ □ □ □ □ □ □ □ □ No Building, Field Location, Greenhouse □ No Delete □ □ □ □ □ □ □ □ 4. Change in Biosafety Level Yes Room Number □ Name 3. Organism/Toxin/Cell Culture Change Add □ Position Yes □ No Training □ Organism/Toxin/Cell Culture □ No □ From ___________ to ____________ Office of Regulatory Compliance & Safety 5. Change in Use of Human Materials Yes Add Delete □ □ □ □ □ □ □ □ □ Yes □ Yes □ Yes □ Yes □ Yes □ Yes □ No □ Type of Material (blood, tissue, body fluids) 6. Change in rDNA Yes Yes □ 2013 □ □ No □ No □ No □ No □ No □ No □ If yes, describe changes in the last column. Host(s) No No □ Host Range Nature of DNA Source of DNA Vector(s) Expression of a Foreign Gene: if yes describe any possible toxicity or hazards Helper Virus/ Defective Virus 7. Change in Laboratory Procedures Yes □ No □ If yes, please summarize. 8. Change in Animal Procedures (species, procedures etc) Yes □ No □ If yes, please describe. 9. Comments: (this page can be used to provide additional information or explanation for the IBC to consider the proposed changes to the project).