Laboratory Demographics
Submitted by:
Date:
Principal Investigator/Director:
Department Chair:
P.I. Blazer I.D.
Department Chair email:
Department:
Contact Blazer ID:
Email:
Building:
Room(s) Inspected:
Lab Type: Clinical
Discipline: Chemistry
Teaching
Research
Chemical Synthesis
Biology
Physics
Other
A. Laboratory Demographics
1.
a. Are select agents used or stored in this lab?
Maximum amount on hand in the lab:
mg/mL
2.
Are biological toxins used or stored in this lab?
List toxins:
Room(s) Stored:
Room(s) Used:
3.
Are bacteria used or stored in this lab?
List Genus:
List Species:
Room(s) Stored:
Room(s) Used:
4.
Are viruses used or stored in this lab?
List Genus:
List Species:
Room(s) Stored:
Room(s) Used:
5.
Are fungi and yeasts used or stored in this lab?
List Genus:
List Species:
Room(s) Stored:
Room(s) Used:
6.
Are parasites used or stored in this lab?
List Genus:
List Species:
Room(s) Stored:
Room(s) Used:
7.
Are r-DNA and/or r-RNA used or stored in this lab?
List Host:
List Vector:
Room(s) Stored:
Room(s) Used:
8.
Are unfixed tissues, blood, fluids, brain or CSF of human origin used or stored
in this lab?
9. Are unfixed tissues, blood or fluids of animal origin used or stored in this lab?
Specify:
Yes
No
NA
Comments
10. Is tissue/cell culture used in this lab?
10a. Primary
Human
Non-human primate
Animal
Source:
10b. Continuous
Human
Non-human primate
Animal
Source:
11. Are animals used in this lab?
Species: Mouse
Rat
Rabbit
Primate
Other Specify
11a. Do you bring animals back to the lab?
11b. If yes, less than 12 hours
or overnight
12. Do you administer anything to the animals?
12a. Infectious Agents
Toxins
RNA/DNA
Chemicals
Anesthetics
12b. Room number of where you administer the agents?
12c. Building where you administer the agents?
12d. How are the agents administered: Oral
Injection
Inhalation
Dermal
IT
13.
Do you work with nanomaterials?