Amendment Request Form

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TEMPLE UNIVERSITY
Office of the Vice Provost for Research
Division of Research Compliance
Institutional Biosafety Committee ~ AMENDMENT
May 2015
Biosafety Registration Number:
Associated ACUP number:
Approval Date:
NIH Category:
Principal Investigator:
Approval Date:
Job Title
Office Phone
Cell/pager
School/College/Center/Department and section (if applicable)
Fax:
Interoffice Address:
e-mail address
Project Title:
Funded internally with department funds
FOAPAL #:
Funded externally by
FOAPAL #:
Is this protocol currently active?
Yes
please complete questions 1 to 4
No
1. Have there been any procedural changes (for example, in the viruses, vector systems or recombinant DNA/biohazards used or are they any changes )
since the last review?
Yes
No
If yes, please attach a brief statement regarding the changes this may require IBC full approval.
2. Have you had any incidents or adverse event?
Yes
No
If yes, please provide the date that was reported to IBC and if applicable to NIH
3. Is there any Change in Personnel?
Yes please complete section below
No
Name
Position
TUID #
Phone number
add*
remove
add*
remove
add*
remove
add*
remove
add*
remove
add*
remove
* If you are adding personnel, please attach the dates of their required trainings and vaccinations.
4. Is there any change in approved location(s)?
Yes please complete section below
Building and Room number
Type of work is performed if applicable
add
remove
add
remove
PI’s Signature
Signature, Chairperson, Institutional Biosafety Committee
Date
Approval Date
No
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