Biosafety Project Approval Certificate Application Form
Applicant information
PI name:
Title/Position:
Permit number (s):
Department:
Name of Person completing application:
Expedited review required:
Justification:
Employee number:
Date:
Lab locations (s):
Faculty:
Approval by Principle Investigator
I declare that I am familiar with the contents of Health Canada’s Laboratory Biosafety Guidelines, 3 rd
Edition (2004) and that the application describes my research program, insofar as this includes the use of
hazardous biological agents and materials, in its entirety.
As the legally responsible individual, I will ensure that all research conducted under my direction in the
above laboratories conforms to the requirements of the University of Manitoba’s Biological Safety Program.
I will ensure that there is full compliance with all the conditions specified on the Biosafety Project
Approval Certificate and that Biological Workers are oriented and trained on the hazards of working with
biological materials, agents and other sources of biological hazards and the safe working procedures.
I understand that if either myself and/or laboratory personnel are found to be in breach of either
institutional and/or Health Canada guidelines all funding maybe frozen until corrective action is taken.
Signature:
Date:
Approval by Department/Unit Head, or Director
By signing, I agree to administer the local requirements for Certification Compliance, including LASH
committees, and WHMIS Coordinator compliance.
Name:
Signature:
Date:
NO ELECTRONIC SIGNATURES
Keep a copy for your records and forward the original to Chair of the Biological Safety Advisory Board
Approval by Review Committee Chair
By signing, I confirm that this application has been peer reviewed to ensure compliance with required
safety protocols.
Name:
Signature:
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Date:
Apr 15 2012
Biosafety Project Approval Certificate Application Form
PI Name:
Project Specific
Project Name:
Applied for
Approved
Funding agency:
To:
Application summary page attached
Funding dates from:
Biohazardous reagents described in the application
1 – in the event that there is a substantial changing in the bioagents, or how they are handled, stored and
disposed of, and/or used in the project, an amendement must be submitted
2 – In the event of a change in biohazard containment level an amendment must be submitted
BIOLOGICAL AGENT USAGE
Indicate usage by checking the relevant boxes.
human tissues and cells
primary human cell cultures
human blood and blood fractions
established human cell lines
human body fluids
Source:
Protocol: Approved
live animals
: Pending
bacteria
viruses
fungi
animal tissues and cells
primary animal cell cultures
animal blood and blood fractions
established animal cell lines
animal body fluids
Source:
Protocol #:
Approval letter appended:
parasites
microbial toxins
recombinant DNA/RNA
Briefly explain why this work is at the level stated:
Stem Cell Oversight Committee/CIHR:
stem cells
Approved
Pending
Stem Cell Oversight
Committee/CIHR Approvals
appended:
other (specify):
Have you completed a PHAC check list?
No
Yes (This may be audited)
Explain:
Agent
Inventory continued on an extra page?
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Biohazard
Containment Level
Yes
Handling/storage/disposal
level
No
Apr 15 2012
Biosafety Project Approval Certificate Application Form
PI Name:
Level One Containment Specific Handling, Storage and Disposal
Handling (Personal protective equipment) tick all that applies
Lab coat
Gloves
Eye protection
Respiration protection
Type:
Other (detail):
Storage
Location:
Refrigerated
Other (please detail):
Frozen
Biological Agent Disposal
Autoclave followed by Regular waste
Other (please detail):
Biological Agent Disposal
Autoclave followed by Regular waste
Other (please detail):
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No
Yes
No
Yes
Locked container
Via UofM Hazardous waste disposal route
Level Two Containment Specific Handling, Storage and Disposal
Handling (Personal protective equipment) tick all that applies
Lab coat
Gloves
Eye protection
Respiration protection
Type:
Other (detail):
Storage
Location:
Refrigerated
Other (please detail):
Close toed shoes
If N95 are all fit-tested?
Frozen
Close toed shoes
If N95 are all fit-tested?
Locked container
Via UofM Hazardous waste disposal route
Apr 15 2012
Biosafety Project Approval Certificate Application Form
PI Name:
Level Three Containment Specific Handling, Storage and Disposal
Handling (Personal protective equipment) tick all that applies
Lab coat
Gloves
Eye protection
Respiration protection
Type:
Other (detail):
Storage
Location:
Refrigerated
Other (please detail):
Biological Agent Disposal
Autoclave followed by Regular waste
Other (please detail):
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Frozen
Close toed shoes
If N95 are all fit-tested?
Locked container
Via UofM Hazardous waste disposal route
Apr 15 2012
No
Yes
Biosafety Project Approval Certificate Application Form
PI Name:
Site Specific Training
Project specific training in Handling Storage and Disposal has been conducted for all named staff
PI directed
Postdoc directed
Technician directed
Signature
Date:
Site Specific Emergency Response: Please list the site specific instructions and safety protocols and spills response
that all lab workers will follow when handling the biohazardous materials specified in this application.
I (the PI) declare that there is full compliance with all the conditions of the specified biohazard containment
levels, and that Biological Workers are oriented and trained on the hazards of working with biological
materials, agents and other sources of biological hazards and the safe working procedures.
Signature
Date:
Final Instructions
NO ELECTRONIC SIGNATURES
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Apr 15 2012