IBC-Renewal/Modification - Office of Research Integrity

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FOR OFFICE OF
RESEARCH
ASSURANCES /
IBC USE ONLY
Approval Date:
Committee ID:
Continuing Review Date:
Expiration Date:
Project Closure Date:
FULL Committee Review Date:
Key Personnel Training: Complete  Incomplete Date of Completion:
ISU INSTITUTIONAL BIOSAFETY COMMITTEE
CONTINUING REVIEW & MODIFICATION FORM
For tri-annual renewals and for changes to projects involving the use of recombinant DNA, infectious agents, or
biological toxins.
 If you have significant changes in procedures and/or organisms, please submit a new application.
 A modification must be approved by the IBC prior to initiation of the modified protocol.
 Please note that every three years, a new full application must be submitted and approved before the expiration date.
Type of submission :
Modification to ongoing project
Third-year renewal
Today’s date:
IBC ID:
IACUC ID (if applicable):
Principal Investigator:
E-mail:
Department:
Address:
Project title:
Is the project active?
Phone:
Yes
No
If No, please enter termination date:
ASSURANCE
 I certify that the information provided in this application is complete and accurate and consistent with any proposal(s)
submitted to external funding agencies.
 I agree to provide proper surveillance of this project to ensure that the rights and welfare of the human subjects or
welfare of animal subjects are protected. I will report any problems to the appropriate compliance review
committee(s).
 I agree that I will not begin this project until receipt of official approval from all appropriate committees.
 I agree that modifications to the originally approved project will not take place without prior review and approval by
the appropriate committee(s), and that all activities will be performed in accordance with all applicable federal, state,
local and University of North Carolina at Greensboro policies.
 I will follow applicable biosafety level requirements; comply with all shipping requirements and required waste
management practices.
 I will ensure that all personnel have appropriate training including but not limited to: biosafety principles and
techniques, accidental spills, shipping regulations, proper handing of biohazardous materials and waste management,
animal welfare regulations, and human subject regulations training.
Signature of Principal Investigator
Date
AUTHORIZATION
Signature of IBC Chair
UNCG Office of Research Integrity
IBC Renewal or Modification Form 11/4/2013
Date
PROPOSED CHANGES:
Please check all that apply. Detail any changes from the previously approved project. Please provide sufficient detail for
each change to allow the Committee to make an adequate review.
Yes
No Are there any changes in project location? (If Yes, please list the changes below.)
Add Delete
Building, field location, or greenhouse
Room number (if applicable)
Yes
No
Have there been any personnel/staff changes since the last IBC approval was granted? If yes, complete
the following sections (Additions/Deletions) as appropriate. List relevant experience of personnel added
to the project. This information is intended to inform the committee of the training and background of
new personnel.
PLEASE NOTE: A change in PI requires submission of a new Protocol Review Form.
Add
Delete
Last
Name
First
Name
Degree
Position at UNCG, Role
and Specific duties on
project
Training Description and Date
of Training
Yes
No
N/A Are there any changes in organisms or toxins used? (If Yes, please list the changes below.)
Add
Delete Organism or toxin
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
N/A
Are there any changes in the Biosafety Level? (If Yes, please list the changes below.)
N/A
For experiments using recombinant DNA, are there changes in any of the following: (If
yes, please provide sufficient identification and background information for the Committee to
make an adequate review).
Host(s):
Host range:
Nature of DNA:
Vector(s):
Physical containment:
Source of DNA:
Deliberate attempt to express a
foreign gene? If yes, describe
and indicate any possible
toxicity or hazards.
UNCG Office of Research Integrity
IBC Renewal or Modification Form 11/4/2013
Yes
Add
No
Delete
N/A For experiments involving animal use, are there changes in species/strain or number of
animals used? Please indicate changes in the table.
TOTAL
APPROX.
NUMBER TO
STRAIN,
COMMON
AGE,
GENUS/SPECIES
BE USED IN
SUBSPECIES
SEX
NAME
WEIGHT OR
ENTIRE
OR BREED
SIZE
PROJECT
E.g., Mus,
musculus
1.
2.
3.
C57BL
Lab Mouse
Yes
No Are there changes in laboratory procedures? (If Yes, please summarize below or in an attachment).
Yes
No
Yes
No
Are there changes in permit requirements? (If Yes, please summarize below). If the appropriate
permits have already been obtained, please list the applicable permit numbers:
Permit:
Permit:
Permit:
Please fax copies of all required permits.
Are there any other changes? If Yes, please describe.
UNCG Office of Research Integrity
IBC Renewal or Modification Form 11/4/2013
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