SECTION X: ADDITIONAL INFECTIOUS MATERIALS
NAME OF PI:
For any of these items, list each material separately (attach additional page if needed):




Infectious organism (Bacteria, Fungi, Parasites, Prions, Rickettsias, Viruses, Yeasts, etc.) not containing recombinant DNA.
When listed, include name of the infectious agent and strain (e.g., Adenovirus type 5, HIV-1 NL4-3, Influenza Virus A/WSn/33,
etc.)
Human and nonhuman primate materials including all fluids, tissues, excretions, secretions, or cell lines not containing recombinant DNA. When listed, include species source and any known viral contaminants/components (e.g., human blood from HIV patients, Macaque tissue, etc.)
Animals or animal specimens known to be reservoirs/vectors of zoonotic diseases. EXEMPT: Animals from Cal Poly ACUCapproved vendors. When listed, specify animal species and any known contaminants.
Other known or potentially infectious materials.
Name of Material
(Identify genus, species,
strain, or known
contaminants, etc)
Risk
Group
2
Source
(Check all that apply)
PI’s Lab
Commercial vendor
Field
Clinical specimens
Primate Center
Univ. Collaborator (specify PI’s name):
Other:
PI’s Lab
Commercial vendor
Field
Clinical specimens
Primate Center
Univ. Collaborator (specify PI’s name):
Other:
PI’s Lab
Commercial vendor
Field
Clinical specimens
Primate Center
Univ. Collaborator (specify PI’s name):
Other:
PI’s Lab
Commercial vendor
Field
Clinical specimens
Primate Center
Univ. Collaborator (specify PI’s name):
Other:
PI’s Lab
Commercial vendor
Field
Clinical specimens
Primate Center
Univ. Collaborator (specify PI’s name):
Other:
Environmental Health & Safety
Form 1, IBC Application 10/28/14
Page 1
Laboratory
Containment
Animal/Plant/Human
Subjects Exposure
Host
Species
Containment
Large
Scale
(>10L of
culture)