Vice President for Research
Office for Research Protections
The Pennsylvania State University
The 330 Building, Suite 205
University Park, PA 16802
(814) 865-1775
Fax: (814) 863-8699
www.research.psu.edu/orp
Institutional Biosafety Committee (IBC) Application
Office Use Only:
(Pathogen Use Teaching Protocol)
****** ALL RESPONSES MUST BE TYPED ******
IBC #: ____________________
(Valid until 12/31/2016)
Complete the items in the form below using as much space as required for each entry. Submit this form
electronically to The Office for Research Protections at ORP-Biosafety@rtto.psu.edu. Transmit it as a
Microsoft Word document or as a Rich Text Format (rtf) attachment from the Principal Investigator’s (PI)
CAC account (i.e., abc123@psu.edu). If you are unable to submit this form electronically, it may be signed
by the PI and mailed to the Office for Research Protections, The 330 Building, Suite 205, University Park,
PA. Handwritten applications are not accepted.
This application is to assist instructors in determining whether the Institutional Biosafety Committee
(IBC) needs to review their proposed use of biohazardous materials in the course of their classroom
activities.
Will organisms pathogenic to humans (requires handling at Biological Safety Level 2 or above)
be used as part of the classroom activities? (If you answered Yes, please complete the below application and
submit it for review to the Institutional Biosafety Committee)
Course Title:
Course Number:
Campus:
Location of Class:
Principal Instructor:
Email:
Mailing Address:
University Status (For example: Faculty, Staff, Post-doc, Grad. Student):
Telephone:
Department:
Campus:
College:
Describe type of contact with each biohazard to be used:
Describe experience with each biohazard to be used:
Describe training the individual will receive (if applicable):
1. What is the duration of the course to be taught:
Start Date:
End Date:
Page 1 of 4
2. Please complete the following table:
Pathogenic Organism
Source
3. NOTE: You must submit the IBC’s Appendix 3, Attachment for the Use of Infectious Agents that
Require Handling Above Biosafety Level 1, with this application.
4. Describe how the biohazardous material will be used in the course of your instruction (e.g.,
demonstration or student handling)?
5. What type of training will students receive prior to handling infectious agents?
6. How will you dispose of the materials once they are no longer needed?
7. Have you considered alternatives to pathogenic organisms? (If yes, why are you still using
pathogens?)
8. List any teaching assistants below (copy and paste table as needed):
NOTE:
 As principal instructor, it is your responsibility to adequately train all individuals conducting procedures
described in this protocol prior to using biohazardous material(s).

As Teaching Assistants are added, you must submit the IBC’s personnel additional form. The personnel
additional form must be approved before personnel may begin work with biohazardous materials.
Teaching Assistant:
Email:
Mailing Address:
University Status (For example: Faculty, Staff, Post-doc, Grad. Student):
Telephone:
Department:
Campus:
College:
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Describe type of contact with each biohazard to be used:
Describe experience with each biohazard to be used:
Describe training the individual will receive (if applicable):
Teaching Assistant:
Email:
Mailing Address:
University Status (For example: Faculty, Staff, Post-doc, Grad. Student):
Telephone:
Department:
Campus:
College:
Describe type of contact with each biohazard to be used:
Describe experience with each biohazard to be used:
Describe training the individual will receive (if applicable):
Teaching Assistant:
Email:
Mailing Address:
University Status (For example: Faculty, Staff, Post-doc, Grad. Student):
Telephone:
Department:
Campus:
College:
Describe type of contact with each biohazard to be used:
Describe experience with each biohazard to be used:
Describe training the individual will receive (if applicable):
Teaching Assistant:
Email:
Mailing Address:
University Status (For example: Faculty, Staff, Post-doc, Grad. Student):
Telephone:
Department:
Campus:
College:
Describe type of contact with each biohazard to be used:
Describe experience with each biohazard to be used:
Describe training the individual will receive (if applicable):
Teaching Assistant:
Email:
Mailing Address:
University Status (For example: Faculty, Staff, Post-doc, Grad. Student):
Telephone:
Department:
Campus:
College:
Describe type of contact with each biohazard to be used:
Page 3 of 4
Describe experience with each biohazard to be used:
Describe training the individual will receive (if applicable):
Teaching Assistant:
Email:
Mailing Address:
University Status (For example: Faculty, Staff, Post-doc, Grad. Student):
Telephone:
Department:
Campus:
College:
Describe type of contact with each biohazard to be used:
Describe experience with each biohazard to be used:
Describe training the individual will receive (if applicable):
ASSURANCES FOR USE OF BIOHAZARDOUS MATERIALS
As the principal instructor for this class, I assure:
1. the information provided on this form accurately summarizes the nature and extent of the proposed use of
biohazardous material(s).
2. all individuals (including students) handling the biohazardous agents described in this application are
technically competent and have been properly trained.
3. That I will obtain approval from the IBC before initiating any changes to this application.
4. I am familiar with and will comply with Penn State’s Policy SY-24, “Use of Biohazardous Material in
Research and Instruction.”
5. all applicable rules and regulations regarding human subjects, vertebrate animals and radiation protection,
etc. have been addressed in the preparation of this application and the appropriate reviews have been
initiated.
E-MAIL TO ORP!
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