ࡱ> [ &bjbj xΐΐp#~~4u:J,$d'333333369f3D)f|D)D)34()))D):3)D)3))r2T3J&~) 234<429)9393(D)D))D)D)D)D)D)33)D)D)D)4D)D)D)D)9D)D)D)D)D)D)D)D)D)~ :  REGISTRATION OF RESEARCH WITH MICROORGANISMS, ONCOGENES, AND TOXINS REGISTRATION #: APPROVAL DATE: DO NOT WRITE IN ABOVE SPACE The NC State University Biosafety Office is required to maintain a'! registry of all laboratories and personnel working with all hazardous and potentially hazardous biological agents or materials. For purposes of this registration, a biological agent is defined as any organism or toxin regardless of biosafety level. AII Biosafety level agents must be registered. The Principal Investigator (PI) is responsible for completing a Biosafety registration form. The registration is needed to maintain a listing of persons at risk for exposure to biological agents. Forward the registration form to EHS, BOX 8007 prior to the initiation of work. Submit a separate Part B for EACH BIOLOGICAL AGENT. Every person listed shall initial the document to indicate they have been informed of: the potential hazards associated with this work, the appropriate safety practices to be used, and the availability of occupational medical programs and applicable educational opportunities. The PI is also responsible for notifying the Biosafety Office when work with the organism is terminated or when other significant changes occur which would require modification of Parts A-C of the registration document. Review and update of registration forms are required every 3 years. An identification number (BIOS REG#) will be assigned to each protocol. When referring to your registration document, please include your BIOS Registration #. EHS conducts annual audits of each registered laboratory to review compliance with NIH/CDC guidelines for practices and procedures appropriate to this work. The audit is not intended to take the place of the responsibilities of the PI in supervising daily work with pathogens. Contact the Biological Safety Officer (5-6858) if you have any questions regarding this program. PART A (PLEASE TYPE OR PRINT) 1. Principal Investigator:  FORMTEXT       Telephone:  FORMTEXT       Supervisor of Project:  FORMTEXT       Telephone:  FORMTEXT       Bldg/Room:  FORMTEXT       Dept:  FORMTEXT       Safety Plan Number:  FORMTEXT       Project Title: FORMTEXT       Type of Registration: New  FORMCHECKBOX  3 Year Renewal  FORMCHECKBOX  (Current BUA #  FORMTEXT      ) List all personnel involved with this project who may be at risk of potential exposure. Include lab technicians, animal care-takers, etc. Please print Employee NameJob TitleInitials FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Have each employee initial the document to indicate the employee has been informed of potential hazards, safe work practices, availability medical surveillance and training opportunities (additional sheet if needed). Please attach a brief overview of the proposed research containing sufficient information to ensure adequate review of the protocol to determine compliance with local, state, and federal regulation. PART B To be completed by laboratories handling biological agents or toxins (Provide complete information for each microorganism in use in your laboratory). 1. Biological Agent or Toxin:  FORMTEXT       Specific Strains, Genotype, or CAS #:  FORMTEXT       Is agent or material a potential human or animal pathogen or toxin? Human  FORMCHECKBOX  Animal  FORMCHECKBOX  Plant  FORMCHECKBOX  None  FORMCHECKBOX  Is agent listed on the CDC List of Select Agents (42 CFR 72.6, Appendix A)? Yes  FORMCHECKBOX  No  FORMCHECKBOX  Is antibiotic resistance expressed? No  FORMCHECKBOX  Yes  FORMCHECKBOX  other markers?  FORMTEXT       5. Location of laboratory: Bldg /Room(s)  FORMTEXT       6. Is a toxin produced? No  FORMCHECKBOX  Yes  FORMCHECKBOX  Work with toxin? No  FORMCHECKBOX  Yes  FORMCHECKBOX  If yes, does toxin have an LD50 more than 100 nanograms per kilogram body weight? Yes  FORMCHECKBOX  No  FORMCHECKBOX  7. Largest volume used is: FORMTEXT       Iiters. Usual volume; used is  FORMTEXT       liters. 8. Is organism inactivated prior to disposal? No  FORMCHECKBOX Yes  FORMCHECKBOX  a. Specify method Used: Heat  FORMCHECKBOX  Chemical  FORMCHECKBOX  Radiation  FORMCHECKBOX  Other  FORMCHECKBOX  b. How do you verify inactivation?  FORMTEXT       9. Do you culture the organism? No  FORMCHECKBOX  Yes  FORMCHECKBOX  10. Do you concentrate the organism? No  FORMCHECKBOX  Yes  FORMCHECKBOX  Specify amount  FORMTEXT       a. Specify methods: Centrifugation  FORMCHECKBOX  Precipitation  FORMCHECKBOX  Filtration  FORMCHECKBOX  Other  FORMCHECKBOX  11. Containment equipment available: Biological Safety Cabinet  FORMCHECKBOX , Containment Centrifuge  FORMCHECKBOX  Other  FORMCHECKBOX  Specify  FORMTEXT       12. Do you radioactively label the organism? No  FORMCHECKBOX  Yes  FORMCHECKBOX  Isotope  FORMTEXT       Where is the labeling done?  FORMTEXT       13. Work with the following tissues  FORMTEXT       cell lines:(indicate whether human or animal source) If human cells are used, complete Part C 14. 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nH uhu*CJOJQJmH nH u++ttuuuwwwxxxxxxlynyyy>z  $^$l$la$ $$D^$]d] $^$anism(s) be used in animals? Yes  FORMCHECKBOX  No  FORMCHECKBOX  If working with animals, is The "Animal Handling Medical Surveillance" in place? Yes  FORMCHECKBOX  No  FORMCHECKBOX  I accept the responsibility for the safe conduct of work with this organism at the Biological Safety Level practices and procedures assigned in Part D. I will inform all personnel, who may be at risk of potential exposure to the organism, of the conditions of this work. Principal Investigator (signature)  FORMTEXT       Date  FORMTEXT       PART C To be completed by laboratories handling human blood, blood components. 1. Location of laboratory: Bldg/Rm(s)  FORMTEXT       2. Identify human samples to be manipulated: Whole blood/serum:  FORMCHECKBOX  Established cell lines:  FORMCHECKBOX  Blood component:  FORMCHECKBOX  Unfixed tissues:  FORMCHECKBOX  Cell "strains":  FORMCHECKBOX  Tissue from animals infected with HIV or HBV: Cell lines or repository cells infected with HIV/HBV:  FORMTEXT       3. Is material freshly harvested? (less than 24 hrs old) No  FORMCHECKBOX  Yes  FORMCHECKBOX  4. From where are cell lines obtained?  FORMTEXT       5. Has material been prescreened for pathogens? No  FORMCHECKBOX  Yes  FORMCHECKBOX  a. If yes, identify any positive tests:  FORMTEXT       b. Are cell lines, strains, or explants characterized; to be free of bloodborne pathogens? No  FORMCHECKBOX  Yes  FORMCHECKBOX  If yes, attach documentation. 6. Has material been infected with any pathogens? No  FORMCHECKBOX  Yes  FORMCHECKBOX  Will the material be infected with any pathogens as a part of this protocol? No  FORMCHECKBOX  Yes  FORMCHECKBOX Material:  FORMTEXT       7. Frequency of manipulations: Daily  FORMCHECKBOX  Weekly  FORMCHECKBOX  Other  FORMCHECKBOX  8. Types of manipulations: Centrifugation  FORMCHECKBOX  Sonification  FORMCHECKBOX  Dissection  FORMCHECKBOX  Blending/Mixing  FORMCHECKBOX  Pipetting  FORMCHECKBOX  Other  FORMTEXT       9.. Containment equipment available: Biological Safety Cabinet  FORMCHECKBOX  Chemical Fume Hood  FORMCHECKBOX  Containment Centrifuge  FORMCHECKBOX  Other  FORMTEXT       I accept the responsibility for the safe conduct of work with the above mentioned human blood, body fluids and/or tissues using the Biological Safety Level practices and procedures assigned in Part D. I will inform all personnel, who may be at risk of exposure to these materials of the appropriate procedures for this work. Principal Investigator (signature) Date PART D To be completed by the NC State University Biosafety Committee, Biological Safety Officer. ******************************************************************************************************************** Biological Safety Officer, Date Biosafety Chairperson Date To be completed by the Biosafety Office upon notification that this work has terminated. ******************************************************************************************************************** Date Registration Document Inactivated: Biosafety Office: `tbtdtntptttttt@uBu^u`ubudujuluu¬sbI:bhu*CJOJQJmH nH u0j$hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH uhTCJOJQJmH nH u0j$hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH u*jhTCJOJQJU^JmH nH uhu*CJOJQJmH nH u*jhTCJOJQJU^JmH nH u0j#hTCJOJQJU^JmH nH uuuuuuwwwxxxx"x$xxxxxxxxxx³ykTkB#hT5>*CJOJQJmH nH u,j%hTCJOJQJUmH nH ujhu*CJOJQJU,jr%hTCJOJQJUmH nH u&jhTCJOJQJUmH nH uhu*CJOJQJmH nH uhTCJOJQJmH nH uhTCJOJQJmH nH u*jhTCJOJQJU^JmH nH u0j$hTCJOJQJU^JmH nH uxxjynyyyyyyyyy*CJOJQJmH nH u>z@zzp{{,|||}~~~02z|6 ]^ @^ $^$ $^$^ D%^ ^ '^z{{${&{({L{N{j{l{n{p{{{{{{{{*|,||||||ɰv]vvF,j")hTCJOJQJUmH nH u0j(hTCJOJQJU^JmH nH uhTCJOJQJmH nH u,j6(hTCJOJQJUmH nH u&jhTCJOJQJUmH nH u0j'hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH u*jhTCJOJQJU^JmH nH uhu*CJOJQJmH nH u||||:}<}X}Z}\}f}h}}}}}}}}}}}}~h~j~~οfοݿOο,j*hTCJOJQJUmH nH u0j*hTCJOJQJU^JmH nH u0j)hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH u*jhTCJOJQJU^JmH nH uhu*CJOJQJmH nH uhTCJOJQJmH nH u&jhTCJOJQJUmH nH ujhu*CJOJQJU~~~~~~~~~  ",.2 ѱщu^uPuAѱhTCJOJQJmH nH ujhu*CJOJQJU,j+hTCJOJQJUmH nH u&jhTCJOJQJUmH nH uhTCJ,OJQJmH nH u0jp+hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH uhu*CJOJQJmH nH u*jhTCJOJQJU^JmH nH u0j*hTCJOJQJU^JmH nH u 8:<x|0246ց؁ѱ‰ѱpѱWHѱhTCJ'OJQJmH nH u0j-hTCJOJQJU^JmH nH u0jH-hTCJOJQJU^JmH nH uhTCJOJQJmH nH u0j,hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH uhu*CJOJQJmH nH u*jhTCJOJQJU^JmH nH u0j\,hTCJOJQJU^JmH nH u "$8:NPR\^bʂ̂΂ނѱ„m_Pѱ70j/hTCJOJQJU^JmH nH uhTCJOJQJmH nH ujhu*CJOJQJU,j /hTCJOJQJUmH nH u&jhTCJOJQJUmH nH u0j.hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH uhu*CJOJQJmH nH u*jhTCJOJQJU^JmH nH u0j4.hTCJOJQJU^JmH nH u6`b24j*҅xz {{{H^H (  '^ `'^ H^H H^HF & FEƀ*Ҳ&.ނ,.04hjʃ̃$٘ꉱpW0jn1hTCJOJQJU^JmH nH u0j0hTCJOJQJU^JmH nH uhTCJOJQJmH nH u0j0hTCJOJQJU^JmH nH uhu*CJOJQJmH nH u0j 0hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH u*jhTCJOJQJU^JmH nH u$&(*LNjln҄Ԅք³ѢѳѢpѳ\E\7\jhu*CJOJQJU,jF3hTCJOJQJUmH nH u&jhTCJOJQJUmH nH u0j2hTCJOJQJU^JmH nH u0jZ2hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH uhu*CJOJQJmH nH uhTCJOJQJmH nH u*jhTCJOJQJU^JmH nH u0j1hTCJOJQJU^JmH nH udf̅΅Ѕ҅ <>@NɰڡɈybO5b3j4hT>*CJOJQJU^JmH nH u$hu*>*CJOJQJ^JmH nH u-jhT>*CJOJQJU^JmH nH uhTCJ%OJQJmH nH u0j24hTCJOJQJU^JmH nH uhu*CJ%OJQJmH nH u0j3hTCJOJQJU^JmH nH u!hu*CJOJQJ^JmH nH u*jhTCJOJQJU^JmH nH uhu*CJOJQJmH nH uNPdfhrtvzډ܉؋ڋދČƌ$&ݩݩݩݩݩvݩvݩݩݩgh<CJOJQJmH nH ujhThTOJQJU#hu*5>*CJOJQJmH nH u#hT5>*CJOJQJmH nH uhTCJOJQJmH nH ujhu*CJOJQJU,j5hTCJOJQJUmH nH uhu*CJOJQJmH nH u&jhTCJOJQJUmH nH u ܉މڋƌ& 0'    '@dh]@H^Hv+p,p-p.p/R 4567:pT/ =!"#$%hh vDText46tDText2tDText3tDText4tDText5tDText6tDText7tDText8tDeCheck1tDeCheck2tDText9$$If!vh5 5 5 #v :V l065 vDText10vDText15vDText20$$If!vh5 5 5 #v :V l065 vDText11vDText16vDText21$$If!vh5 5 5 #v :V l065 vDText12vDText17vDText22$$If!vh5 5 5 #v :V l065 vDText13vDText18vDText23$$If!vh5 5 5 #v :V l065 vDText14vDText19vDText24$$If!vh5 5 5 #v :V l065 vDText25vDText26tDeCheck3tDeCheck4tDeCheck3tDeCheck4tDeCheck5tDeCheck6tDeCheck7tDeCheck8vDText27vDText28tDeCheck9vDeCheck10vDeCheck11vDeCheck12vDeCheck13vDeCheck14vDText29vDText30vDeCheck15vDeCheck16vDeCheck17vDeCheck18vDeCheck19vDeCheck20vDText31vDeCheck21vDeCheck22vDeCheck23vDeCheck24vDText32vDeCheck25vDeCheck26vDeCheck27vDeCheck28vDeCheck29vDeCheck31vDeCheck32vDText33vDeCheck33vDeCheck34vDText34vDText35vDText36vDeCheck35vDeCheck36vDeCheck37vDeCheck38vDText37vDText38vDText39vDeCheck39vDeCheck42vDeCheck40vDeCheck43vDeCheck41vDText40vDeCheck44vDeCheck45vDText41vDeCheck46vDeCheck47vDText42vDeCheck48vDeCheck49vDeCheck50vDeCheck51vDeCheck52vDeCheck53vDText43vDeCheck54vDeCheck55vDeCheck56vDeCheck57vDeCheck58vDeCheck59vDeCheck60vDeCheck61vDText44vDeCheck62vDeCheck63vDeCheck64vDText45^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH L`LTNormal1$ B*_HmHnHphsH tH uX@X T Heading 1$d@&]8a$5CJOJQJ\uV@V T Heading 2$!@&^`5CJOJQJuDA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List FB@F T Body Text !CJOJQJuPK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! 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