Page 1 CDC SELECT AGENT SURVEY Principal Investigator/Name_____________________________ Date ___________________ Department ___________________________Room #____________Phone_________________ Title of Project: ________________________________________________________________ Please check one of the following: ____ I have reviewed the list of select agent microorganisms and toxins and I do not possess or use any of these agents. ____ I do possess and/or use one or more of the select agents and have checked the agents I possess below. ____ I do not currently possess or use any of the select agents but plan to do so in the future. I have indicated those I plan to use below. CDC Select Agents (Appendix A to 42 CFR Part 73) Viruses ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 1. Cercopithecine herpesvirus 1 (Herpes B Virus) 2. Crimean-Congo haemorrhagic fever virus 3. Eastern Equine Encephalitis virus 4. Ebola viruses 5. Equine Morbillivirus 6. Lassa fever virus 7. Marburg virus 8. Monkeypox Virus 9. Nipah and Hendra Complex viruses 10. Rift Valley fever virus 11. South American Haemorrhagic fever viruses (Junin, Machupo, Sabia, Flexal, Guanarito) 12. Tick-borne encephalitis complex viruses 11. Variola major virus (Smallpox virus) 12. Venezuelan Equine Encephalitis virus 13. Viruses causing hantavirus pulmonary syndrome 14. Yellow fever virus Bacteria ____ ____ ____ ____ ____ 1. 2. 3. 4. 5. Bacillus anthracis Brucella abortus, B. melitensis, B. suis Burkholderia (Pseudomonas) mallei Burkholderia (Pseudomonas) pseudomallei Clostridium botulinum D:\116102708.doc Page 2 ____ 6. Francisella tularensis ____ 7. Yersinia pestis Rickettsiae ____ 1. Coxiella burnetii ____ 2. Rickettsia prowazekii ____ 3. Rickettsia rickettsii Fungi ____ 1. Coccidioides immitis ____ 2. Coccidioides posadasii Toxins ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 1. Arbin 2. Aflatoxins 3. Botulinum toxins 4. Clostridium perfringens epsilon toxin 5. Conotoxins 6. Diacetoxysirpenol 7. Ricin 8. Saxitoxin 9. Shigatoxin 10. Staphylococcal enterotoxins 11. Tetrodotoxin 12. T-2 toxin Attenuated Select Agents (Genetic Elements, Recombinant Nucleic Acids and Recombinant Organisms) ____ 1. Select agent viral nucleic acids (synthetic or naturally derived, contiguous or fragmented, in host chromosomes or in expression vectors) that have potential to encode infectious and/or replication competent forms of any of the select agent viruses. ____ 2. Nucleic Acids (synthetic or naturally derived, and that are in a vector or host chromosome; can be expressed in vivo or in vitro; or are in a vector or host chromosome that can be expressed in vivo or in vitro) that have the potential to encode for the functional form(s) of any of the toxins from the select agents listed above, OR their toxic sub-units. ____ 3. Any of the viruses, bacteria, fungi, and toxins listed above that have been genetically modified. PI Signature: _______________________________________________________________ **** Mail completed survey to EHS at Fuller Building 470 or fax to 638-8822 **** D:\116102708.doc