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