UNIVERSITY OF MIAMI
INSTITUTIONAL BIOSAFETY COMMITTEE
EXEMPTION REQUEST FORM
Principal Investigator:
Phone:
Degree:
Fax:
Department:
Email:
Title of Project:
Building:
Room #:
Funding Source:
Start Date:
Locator Code:
Lab Location:
Grant/Proposal #:
ACUC Number (if applicable):
List title on IACUC or IRB protocol form if different from above:
The NIH guidelines for research involving recombinant DNA molecules (NIH Guidelines) can be found on the
web at http://oba.od.nih.gov/oba/rac/guidelines_02/NIH_Guidelines_Apr_02.htm
This study ONLY involves recombinant DNA molecules that:
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are not in organisms or viruses. Exempt (III-F-1)
Yes
No
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consist entirely of DNA segments from a single non-chromosomal or viral DNA source.
Exempt (III-F-2)
Yes
No
consist entirely of DNA from a prokaryotic host when propagated in that host.
Exempt (III-F-3)
Yes
No
consist entirely of DNA from a eukaryotic host when propagated in that host.
Exempt (III-F-4)
Yes
No
consist of DNA from different species that exchange DNA through known physiologic
processes. Exempt (III-F-5)
Yes
No
do not present risk to health or environment as determined by the NIH Director.
(See Appendix C of the NIH guidelines) Exempt (III-F-6)
Yes
No
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If your study does not meet any of the exemption criteria listed above, your application will require full review
by the Institutional Biosafety Committee (IBC). Please visit our website and fill out the appropriate form for
IBC review. http://www.miami.edu/rdna/
If your study does qualify for an exemption, please complete questions 1&2 below. Then email this form to
Ekapsali@med.miami.edu AND fax one signed copy to Ellen Kapsalis, PH.D. at 305-243-2853 for IBC review. The
approved application will be faxed back to you after the chairman’s review.
1. Provide a brief description of the research objectives.
Last Updated: 09/05/2006
2
2. Please provide the following information:
Source(s) of DNA
Host(s)
Vector(s)
Experimental Use *
*Please describe the intended application of the rDNA molecule. If your intent is to express a certain gene
(protein), please indicate which gene. Refer to Appendix A in the NIH guidelines for examples.
http://oba.od.nih.gov/oba/rac/guidelines_02/NIH_Guidelines_Apr_02.htm
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Principal Investigator's Signature
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Print Name
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Date
Last Updated: 09/05/2006