IBC Received Date Stamp—Office Use Only
IBC Protocol Number—Office Use Only
Institutional Biosafety
Committee
IBC Protocol Amendment Form
For Research Involving Recombinant DNA, Pathogens and/or Human Sera/Tissue
Instructions:
1. Complete all sections of this form.
2. Obtain all necessary signatures.
3. Submit one complete protocol electronically.
Note:
1. Handwritten forms will not be accepted.
2. INCOMPLETE FORMS WILL BE RETURNED.
3. Please retain a copy of the completed form for your records.
1. Submittal Date:
mm/dd/yyyy
Research Protocol Number:
Research Protocol Title:
2. Amendment Requested:
Change in Principle Investigator’s Status (department, mailing address, office location, etc.). Describe:
Change in Location of Project. Describe:
Change in Date(s) of Project. Describe:
Addition of Personnel.
Name and Departments
Role in Protocol
Specific Experience with Materials in Protocol
Deletion of Personnel. Names:
Addition or Deletion of Agent(s) being used. Describe:
Change in Procedures. Describe:
Change in safety controls (biosafety levels, addition or deletion of biosafety cabinet, etc.). Describe:
Other change. Describe:
3. Investigator Assurance
I certify that the information provided in this amendment form is complete and accurate. As Principal Investigator, I have ultimate responsibility for
the conduct of this study, the ethical performance of the project, the biosafety controls and strict adherence to any stipulations designated by the IBC.
I agree to comply with all UNLV policies and procedures, as well as with all applicable Federal, State and local laws regarding recombinant DNA,
pathogens and human sera/tissue research including, but not limited to the following:

Performing the project by qualified personnel according to the approved protocol.

Obtaining adequate training in the safe handling of recombinant DNA, pathogens and human sera/tissue.

Promptly reporting adverse events to the Office of Research Compliance in writing.
_______________________________
Principal Investigator’s Name
_________________________________
Principal Investigator’s Signature
_________
Date
Forwarding Instructions
Send completed form to:
Office of Research Integrity
4505 Maryland Parkway Box 451087
Las Vegas, Nevada 89154-1087
ORI Telephone Number:
ORI FAX Number:
ORI E-mail Address:
ORI Webpage:
(702) 895-5948
(702) 895-5464
kevin.bergeron@unlv.edu
http://www.unlv.edu/Research/compliance/
Protocol Amendment Form 10/05
1 of 1