Transgenic Animal
Registration Form
IBC Use Only
Registration # _________
THIS APPLICATION MUST BE TYPEWRITTEN
Use this form only for experiments involving the generation of transgenic animals that require BL-1
containment. This form can be submitted simultaneous with initiation of the experiment. For experiments that
require BL-2 containment or higher, please use the Recombinant DNA & Synthetic Nucleic Acid Registration
Form. If you are unsure what biosafety level your work falls under, please contact the Biosafety Officer at the
number listed below.
Transgenic and knockout animals made in the mouse core facility will be registered on an annual basis by
the core facility. Thus, if your transgenic animals are made by the mouse core facility, you do not need to
register separately.
1.
2.
3.
4.
Principal Investigator:
Department/Division:
Office Address:
Lab Address:
M.D. [ ] Ph.D. [ ] Other:
Email:
Phone:
Phone:
5. List all professional personnel, employees and students involved in the project. Attach an additional
sheet if needed.
Name
Job Title
Lab Address
Phone Number
6. Project Title and IACUC Registration Number:
7. Type of animal to be used?
8. Specify the transgene(s) or family of
transgenes to be inserted. Plasmid maps
may need to be provided if there is a risk of
transmission/transduction to humans.
9. Will known or potential human, animal, or
plant pathogens be used in this research?
Yes [ ] No [ ]
If yes, please specify the genus, species, and strain:
Proposed Containment Level: BL1 [ ] BL2 [ ] BL3 [ ]
10. Building and room number where
transgenic or knockout animals will be
created?
11. Building and room number where
transgenic animals will be housed?
12. Attach a short, clear summary of your proposed project. Avoid jargon and excess technical detail. Address
each of the following items and include any other data that you feel has important bearing upon the safety and
the proposed containment for this project.
a. Please provide a brief description of the proposed experiments.
University of Utah R-DNA Registration
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b. Specifically identify the gene(s) of interest, including a description of any associated hazards (i.e.
genes that code for toxic, oncogenic, or otherwise hazardous peptides), that will be used in the
creation of transgenic animals listed in #9 above.
c. Identify and describe the risks to humans associated with this project.
d. Identify and describe any ecological advantages/disadvantages that transgenic animals might
acquire through the proposed genetic recombination.
e. Describe the containment procedures that will be followed to prevent the escape of transgenic
animals from the laboratory.
13. I hereby apply for approval of my plans for experiments involving the creation of transgenic animals
and any associated work with recombinant or synthetic nucleic acid molecules. I am familiar with, and
agree to abide by, the provisions of the current NIH Guidelines (April 2002 Federal Register (or later)
and appendices), and any other specific NIH or University of Utah instructions pertaining to the
proposed project. I agree to provide the IBC prompt written notification of any significant changes in
these protocols or of any major accidents involving the release of transgenic animals. I agree to comply
with NIH requirements pertaining to shipment and breeding of transgenic animals.
I accept responsibility for the safe conduct of work as indicated on any page of this form, and in any
additional information submitted in connection with this application, or updating or revising this
application. I will ensure that all personnel receive appropriate training in regard to containment of
transgenic animals, proper safety practices and personal protective equipment needed for this work and
that all building occupants are educated when warranted.
I certify that all herein provided information, and any subsequent information submitted in connection
with this application, is accurate and complete.
Principal Investigator (signature/date):_____________________________________________________
Send a copy of completed forms to the following individual:
Biosafety Specialist / IBC Administrator
Environmental Health & Safety
University of Utah
125 S. Fort Douglas Blvd., Building 605
Salt Lake City, Utah 84113
Office (801) 581-6590
Fax (801 585-7240
e-mail biosafety@ehs.utah.edu
6/27/2012
University of Utah R-DNA Registration
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