Institutional Biosafety Committee
Recombinant DNA Application
Memorandum of Understanding and
Agreement
Instructions for this Form: YOU MUST save this form to your hard drive (click File>Save
As…), then open it from the version saved on your computer. You should be able to fill it out
electronically and then print it. Then sign it and send it to the Dean of Graduate Studies and
Research, Room 401 Cohodas.
I.
Project Title
Principal Investigator
Phone Number
Title
Department
Mailing Address
Grant Agency
Grant number
Grant Pending
Yes
II.
No
Facilities
Building
Room number
Physical Containment Level*
Biological Containment Level*
III. Host/Vector Information
Host Name
1.
2.
3.
IBC Recombinant DNA Application
Biosafety Class*
Vector
1
*See NIH Guidelines for Research involving Recombinant DNA Molecules
IV. Nature of DNA
Previously cloned
Natural or cDNA
Synthetic
Source of DNA (genus and species)
V.
Will any human blood or tissue, or any infectious microorganism (other than an NIH
approved host or vector) be used in this research?
Yes
No
If yes, attach an approved infectious agents application.
VI. Will there be a deliberate attempt to express any protein gene products?
Yes
No
If yes, please describe the amount of protein and its nature
VII. Description
Provide a brief description of the experiments to be conducted which involve
recombinant DNA molecules. Include (a) the experimental approach, (b) your rationale
for choosing the physical and biological containment levels indicated in question #3 (cite
pertinent section(s) from NIH Guidelines), c) an assessment of the hazardous potential if
cloning any DNA segments encoding pathogenic, oncogenic, or toxic substances (if this
application does not involve such substances, please indicate so), and (d) the significance
of the research.
IIX. Principal Investigator Statement
I have read and agree to abide by the most recent NIH Guidelines regarding recombinant
DNA published in the Federal Register. Furthermore, I agree to do the following:
A. Ensure that my laboratory conforms to Biosafety Level 1 criteria as described in the
CDC/NIH Biosafety in Microbiological and Biomedical Laboratories.
B. Ensure that personnel have received training in safe laboratory practices.
C. Immediately inform the Biosafety Officer of any significant research related accident
or illness.
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D. Request approval for significant modifications to the study, facilities or procedures.
E. Inform those working on this project about the availability of health surveillance,
about advisable or required precautionary medical practices and about the opportunity
of receiving care at the Employee Health Service.
F. Comply with NIH requirements pertaining to shipment and transfer of recombinant
DNA materials as stated in the NIH guidelines and in all supplemental instructions
provided to the Biosafety Committee and to me.
G. Abide by all subsequent instructions issued by the granting agency and received by
me.
Signature: _____________________________________________________________________
Principal Investigator
Date
IX. Biosafety Committee Approval
The Biosafety Committee has reviewed this MUA application and has found the
proposed research to be in compliance with the University and NIH Recombinant DNA
guidelines.
Signature: _____________________________________________________________________
Chair; IBC Subcommittee on recombinant DNA
Approval Date
THE INFORMATION IN THIS DOCUMENT MAY BE MADE PUBLIC UPON PROPER
REQUEST.
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