IBC Closure Notification Form - Environmental Health and Safety

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IBC Protocol
Closure Notification Form
IBC Use Only
Registration # _________
THIS APPLICATION MUST BE TYPEWRITTEN
*Principal Investigators must use this form to notify the IBC of their impending relocation and protocol closure.
Timely submittal of this form allows update of records required by granting and regulatory agencies, and will
permit continued use of biological agents without interruption during the transition.
1.
2.
3.
4.
Principal Investigator:
Department/Division:
Office Address:
Lab Address:
M.D. [ ] Ph.D. [ ] Other:
Email:
Phone:
Phone:
5. List any personnel and students approved by the IBC that will remain to work on these experiments
during the transition. Attach an additional sheet if needed.
Name
Job Title
Lab Address
Phone Number
6. Project Title:
7. IBC Registration Number (located on approval letter):
8. Identify the Building and Room Number where the experiments have been conducted:
9. Study Closure Date:
10. Is there still product/agent on site?
YES
NO
11. Are there decontamination procedures in place for disposal of unused or remaining agent(s)?
YES
NO
11. If yes, where will the product/agent be disposed?
ONSITE
12. If offsite, please provide:
Where it will be disposed:
OFFSITE
How it will be disposed:
Principal Investigator (signature/date):_____________________________________________________
Send a copy of completed forms to the following individual:
Biosafety Officer
University of Utah
Environmental Health and Safety
Bldg. 605
Telephone: 801-581-6590
FAX: 801-585-7240
e-mail [email protected]
University of Utah IBC
Amendment to Registration
Page 1 of 1
06/13/2013
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