RECOMBINANT DNA APPLICATION

TO THE INSTITUTIONAL BIOSAFETY COMMITTEE

 

 

PLEASE DO THE FOLLOWING:

 

1.     FILL OUT THE FORM

2.     PRINT IT OFF

3.     SIGN IT

4.     DELIVER (OR CALL X55623 FOR PICKUP) TO KRISTIN HUNTER PH3-018, OR FO5-120 MAILBOX

 

THE INSTITUTIONAL BIOSAFETY COMMITTEE (IBC) WILL REVIEW YOUR APPLICATION

 

PLEASE CALL X55623 IF YOU HAVE QUESTIONS

 

THANK YOU.

 

 

 

APPLICATION TO USE RECOMBINANT DNA (rDNA), ETIOLOGIC AGENTS AND rDNA WITH ETIOLOGIC AGENTS

 California State University, Long Beach

Institutional Biosafety Committee

 

 

Name:      

Dept:      

Date:       

 

 

 

 

This research is subject to annual review and renewal.  This form must be typed.

 

SECTION 1: RESEARCH DESCRIPTION

 

Describe the work to be conducted in your laboratory directly related to etiologic agents and/or rDNA (include general experimental procedures):

 

     

 

SECTION 2: CHECK ALL THAT APPLY TO THE RESEARCH DESCRIBED ABOVE

 

Infectious Agents                                                                Use of Recombinant DNA

 

 Viruses                                                                              rDNA

 Bacteria                                                                             Intentional release to environment

 Fungi                                                                                 Transgenic Animals

 Prions                                                                                Transgenic Plants

 Parasitic Agents

 Pre-exposure immunization required

 

 

Use of Animals

 

 Invertebrates  Identify:      

 Vertebrates      Identify:          AWB Protocol #:      

 Use of infectious agents in animals

 Use of animals that are potential reservoirs of zoonotic diseases

 

 

 

SECTION 3: USE OF RECOMBINANT DNA (rDNA)

 

Provide the following information for the use of rDNA:

 

a)       Nature of inserted DNA sequence, including the species of origin, gene product and function (if known):

     

b)       Host(s) and vector(s) to be used:

     

c)       Will an attempt be made to express the foreign gene?                           Yes                    No

 

SECTION 4: RISK ASSESSMENT AND RISK GROUP (RG)

 

Check the Risk Group (RG) of the agent being used (see appendix B of the NIH guidelines copied for you at the end of this application, and also found at http://www4.od.nih.gov/oba/RAC/guidelines/appendix_b.  )

 

 RG1    RG2    RG3    RG4

 N/A (no etiologic agent will be used)

 

Identify the RG agent(s) being used:

 

     

 

SECTION 5: PHYSICAL CONTAINMENT AND BIOLOGICAL SAFETY LEVEL (BSL)

 

Check the BSL of the agent being used (see appendix G of the NIH guidelines copied for you at the end of this application, and also found at:  http://www4.od.nih.gov/oba/RAC/guidelines/appendix_g.htm

  

 

 Exempt              BSL-1                BSL-2                BSL-3 Practices/BSL-2 Facility

 BSL-3              

 

SECTION 6: LOCATIONS FOR USE AND STORAGE OF ETIOLOGIC AGENTS AND rDNA

 

List the location(s) where work will be conducted and where materials will be stored. 

 

Building

Room Number

 

     

     

     

     

     

     

     

     

     

 

Does this project involve CSULB-managed funds for the use of rDNA or etiologic agents at a site other than UCI?     

 Yes                    No

 

If yes, please list the site(s) here:      

 

SECTION 7: DECONTAMINATION PROCEDURES

 

Read the decontamination procedures for personnel, equipment, and laboratory areas as defined for your BSL level in Appendix G of the NIH Guidelines copied for you at the end of this application, and also found at http://www4.od.nih.gov/oba/rac/guidelines/guidejan01.htm.  Do you agree to abide by these guidelines and also work in accordance with the CNSM Biohazard Program policy (copied for you at the end of this application) with respect to decontamination procedures?

 

 Yes                    No

 

 

SECTION 8: DISPOSAL OF CONTAMINATED MATERIALS

 

Do you agree to dispose of all contaminated materials according to CNSM Biohazard Program policy (decon first via autoclave, chlorox etc. as appropriate; sharps into sharps containers; etc)? 

 

 Yes                    No

 

 

SECTION 9: TRAINING OF PERSONNEL

 

Describe how personnel have been trained in the handling of agents to be used (e.g. hands-on training in the lab, lab meeting, etc.).

 

     

 

Section 10: ACCIDENTAL EXPOSURE

 

Do you agree to contact CNSM Safety/Campus Safety & Risk Management immediately in the event an employee, student, or coworker becomes ill and/or exhibits symptoms and signs consistent with an infection by an organism used in this research?

 

 Yes                    No

 

 

Annual Renewals: Have there been any adverse events related to work with this organism over the past year?               Yes                    No

 

 

 

If yes, please describe:      

 

 

DEPARTMENTAL APPROVAL

Note to applicant:  The CNSM Safety Office will obtain this signature for you.

 

The Department Chair/Director must read the protocol and sign below indicating department approval before IBC review may occur.  Note: If the Department Chair/Director is an investigator on this application, this approval must be obtained from the next highest level of administrative authority.

 

I hereby confirm that I have read the Protocol Narrative and can certify that: 1) the research is appropriate in design; 2) the investigator (or faculty sponsor) is competent to perform (or supervise) the study; and 3) there are sufficient funds available to support performance of this research.  My signature below denotes Departmental Approval of this study as submitted.