FOR BIOSAFETY OFFICE USE ONLY:
(Date Stamp)
IBC #:
For Unique Identification
Biological Safety Office
Course-based Application for Teaching
Laboratories
For assistance completing this form, contact:
Biosafety Officer
Danielle Daniely, Ph.D.
Email: ddaniely@gru.edu
Phone: 706-721-2918
Assistant Biosafety Officer
Laura Meyer, MA
Email: lmeyer@gru.edu
Phone: 706-721-7458
 Please submit a separate application for each course (a separate form is not
needed for each instructor/section unless a different set of labs is used)
 It is not necessary to submit a new application each semester unless there is a
change in instructors, agents, locations or laboratory procedures.
 Complete this form electronically (must be typed) and save as Course#_Instructor
(FirstLast). Example: BIOL1102_JohnDoe (please use the name of the first
instructor listed below)
 Submit a copy of laboratory syllabus/list of laboratory experiments along with the
application.
 Submit the electronic documents to the Biosafety@gru.edu email account
Return by email to:
Environmental Health & Safety - Biosafety
Email: biosafety@gru.edu
Mail: 1405 Goss Lane, CI-1006
Augusta, GA, 30912
Phone: 706-721-2663
Fax:
706-721-9844
GENERAL INFORMATION
Is this a new or a revised application?
Course #:
New application
Revised application, will replace (previous Course#_Instructor):
Course title:
List instructors for all sections of this course:
Main Instructor:
Office Phone Number:
Laboratory Phone Number:
Department:
Emergency Phone Number:
Email Address:
Co-Instructor:
Office Phone Number:
Email Address::
Co-Instructor:
Office Phone Number:
Email Address::
Mark all sections below that are applicable to your course:
Recombinant and Synthetic Nucleic Acid Molecules (e.g., bacterial/mammalian
expression plasmids, replication incompetent viral vectors, chemically synthesized nucleic
acid molecules)
Human & Non-Human Primate Material (e.g., blood, fluids, tissues, primary/established
cell lines)
Microorganisms/Potentially Infectious Material (e.g., viruses, bacteria, yeast, fungi,
parasites, prions)
Whole Animals/Animal Material (e.g., introduction of biologicals/chemicals into animals,
use of animal cell lines and/or tissues)
Biological Toxins (e.g., cholera toxin, pertussis toxin, diphtheria toxin, tetrodotoxin)
Applicable
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Nanoparticles (e.g., use of Jet-Pei or Poly-L-Lysine to form nano-sized particles)
Yes
No
Arthropods (e.g., insects, spiders, crabs, lobsters, shrimp)
Yes
No
Plants (e.g., toxic/transgenic plants)
Yes
No
List all locations utilized for this course:
Facility Type
(i.e. Prep room, Classroom, Tissue Culture, Greenhouse, Field,
Microscope Room):
Prep room
Classroom/Lab
Other (specify):
Prep room
Classroom/Lab
Other (specify):
Building Code and Room
Number:
Biosafety
Level (BSL):
Prep room
Prep room
Classroom/Lab
Classroom/Lab
Other (specify):
Other (specify):
Course details:
Please answer questions 1-13. If you answer “yes” to any question, please provide the appropriate details following each question
to allow the IBC to make an adequate review.
1. Is laboratory safety training a part of your course/program?
Yes
If yes, please indicate how this training is documented. If no, please contact the Biological Safety Office for assistance in
developing safety training.
No
2. What types of PPE (Personal Protective Equipment) are required for this course?
Personal Protective Equipment (PPE):
(Mark all PPE to be worn while conducting experiments covered in this application)
Gloves:
Nitrile
Latex*
Provided by instructor/department
Other(list):
Purchased by students
*Exposure to latex may cause severe allergies for some
individuals
Mucous
Membrane
Protection:
Safety Glasses
Face Shield
Other (list):
Protective
Clothing:
Tie Back Lab Coat
Disposable Gowns
Other (list):
Goggles
Plexiglass Shield
Button Front Lab Coat
Provided by instructor/department
Purchased by students
Provided by instructor/department
Purchased by students
If a lab coat is required, how will it be cleaned once dirty or contaminated? (Check all that apply)
Not applicable – disposable protective clothing will be used
Laundered with a qualified commercial service
Laundered/soaked on-site with bleach
Other (specify):
3. Does your course involve the use of recombinant DNA (rDNA)?
Yes
No
If yes, please provide details regarding the nature of the rDNA and how it will be used in your course. Please be as specific as
possible about the vector and insert (provide a vector map if available), the source of the material (i.e. purchased from a vendor,
constructed in the laboratory), how it will be propagated (i.e. bacterial strain or cell line), and whether the rDNA will be used in
experiments involving living organisms (i.e. bacteria, mice, plants, arthropods).
4. Does your course involve the use material from humans or non-human primates?
Yes
No
If yes, please provide details regarding the material that will be used in your course. Please be as specific as possible about the
type of material (i.e. cell lines, blood, saliva, muscle), whether it is from human or non-human primate, the source of the material
(i.e. purchased from a vendor, collected from volunteers, clinical specimens), any treatment or testing that has been done (i.e. fixed
with formalin, tested for pathogens), and how the material will be used.
5. Does your course involve the use of microorganisms (bacteria, yeast, viruses)?
Yes
No
If yes, please provide details regarding the organisms that will be used in your course. Please indicate the specific strains, the
source (i.e. purchased from a vendor, obtained from a collaborator), and how the material will be used.
6. Does your course involve the use of animals or animal tissues, cells, or cell lines?
Yes
No
If yes, please provide specific details regarding the type of animal, source (field caught, purchased from a vendor), Institutional
Animal Care and Use Committee approval information (if available), and how the animals will be utilized in the course.
8. Does your course involve the use of biological toxins?
Yes
No
If yes, please provide details regarding type of materials that will be used in your course. Please be as specific as possible about
the type of toxin, the source (i.e. purchased from a vendor, obtained from a collaborator), LD50 if known, maximum amount on hand
for the course, antidote information if available, and how the toxin will be used.
9. Does your course involve the use of nanoparticles or nano-sized materials?
If yes, please provide details regarding the type of particles or materials that will be used and the intended use.
Yes
No
10. Does your course involve the use of arthropods?
Yes
No
If yes, please provide details regarding the type of arthropods that will be used in your course and how they will be used. Please
indicate whether wild type or transgenic arthropods will be used or if the arthropods will be exposed to rDNA.
11. Does your course involve the use of plants?
Yes
No
If yes, please provide details regarding the type of plants that will be used in your course and how they will be used. Please
indicate whether wild type or transgenic plants will be used or if the plants will be exposed to rDNA.
12. Does your course generate biohazardous waste?
If yes, please describe your waste handling procedures.
Yes
No
13. Is a biosafety cabinet (tissue culture hood) available for use in your course?
Yes
No
If yes, when was the cabinet last certified?
INSTRUCTOR’S ASSURANCE
Please review each of the following terms of this agreement prior to electronically signing this agreement, below.
1.
2.
3.
4.
5.
6.
7.
8.
I attest that the information contained in the attached application and supplements is accurate and complete.
I agree to comply with the requirements pertaining to the use, shipment and transfer of biological agents.
I will ensure that before entering my laboratory, any person is advised of the potential hazards.
I agree to accept responsibility and accountability that all students are familiar with and trained to employ the appropriate safety
precautions, emergency procedures, and the practices and techniques.
I agree to verify this application and to amend to include any changes in agents, locations or significant changes in laboratory
procedures before the start of each semester.
I agree to report any accident that results in overt exposure of students or the environment to biological agents or recombinant DNA
including inoculation, ingestion, mucous membrane exposure or inhalation by personnel of any agent to the Biosafety Officer (x1-2663),
followed by completion of the accident report found on the Biosafety webpage.
I agree to immediately report any high hazard spills (large volumes, high risk group agents) or spills in public (non-laboratory) areas to
the Biosafety Officer (x1-2663).
I agree to report any problems pertaining to operation and implementation of biological and physical containment safety procedures or
equipment or facility failures to the Biosafety Officer (x1-2663) as soon as possible, followed by a written report.
Main Instructor
Date
(By electronically entering your name, you are indicating verification that all
items are accurate and you agree to ensure compliance with the above items.)
Co-Instructor
Date
(By electronically entering your name, you are indicating verification that all
items are accurate and you agree to ensure compliance with the above items.)
Co-Instructor
(By electronically entering your name, you are indicating verification that all
items are accurate and you agree to ensure compliance with the above items.)
Date
***Please save this form as Course#_InstructorName (FirstLast) and submit electronically to
Biosafety@gru.edu***