ࡱ>  bjbjVV R<<md d     ,7 =v////46J7dssssssswzs174@477s//u4;4;4;78//s4;7s4;4;N4j0o/o 7k0s v0=v l${7v{`0o{0o774;77777ss4;777=v7777{777777777d m:  BIOLOGICAL USE AUTHORIZATION Form Revised 04/2011 Registration #: FORMTEXT       IBC Approval Date:  FORMTEXT       NIH Classification(s):  FORMTEXT       Containment Level(s):  FORMTEXT       -------------------------------------------------- DO NOT WRITE ABOVE THIS SPACE Directions: All biological agents, regardless of risk group classification, are registered at NC State using this form. Biological materials you may not consider to be hazardous may be regulated under federal, state, or local statutes and guidelines as biohazardous materials. The risk can be direct through infection or indirect through damage to the environment. Examples of biological agents include recombinant DNA in organisms, creation of transgenic plants or animals, human and other primate-derived substances (blood, body fluids, cell lines or tissues), organisms and viruses infectious to humans, animals or plants (e.g. parasites, viruses, bacteria, fungi, prions, rickettsia); and biologically active agents (i.e. toxins, allergens, venoms) that may cause disease in other living organisms or cause significant impact to the environment or community. The Principal Investigator (PI) is responsible for completing and submitting the Parts of this form that pertain to the research being registered. Omit any Part of the form that does not pertain to your research. Initiation of proposed project involving use of biological materials is dependant upon IBC approval. Completed forms must be signed by the PI and sent to Biological Safety Officer, Environmental Health & Safety at Campus Box 8007 or emailed to the Biological Safety Officer at  HYPERLINK "mailto:darren_treml@ncsu.edu" darren_treml@ncsu.edu from the PIs email address. Part A: General Information (PLEASE TYPE or PRINT CLEARLY) Principal Investigator:  FORMTEXT       Telephone:  FORMTEXT    - FORMTEXT    - FORMTEXT      Dept Name:  FORMTEXT       Lab Supervisor:  FORMTEXT       Telephone:  FORMTEXT    - FORMTEXT    - FORMTEXT      Campus Box #:  FORMTEXT      Safety Plan #:  FORMTEXT       Project Title:  FORMTEXT       Type of Registration:  FORMCHECKBOX  New Registration Location(s): Bldg/Room:  FORMTEXT        FORMCHECKBOX  Amendment to Reg #  FORMTEXT       Bldg/Room:  FORMTEXT        FORMCHECKBOX  3 Year Renewal (Current Reg # s  FORMTEXT      ) Bldg/Room:  FORMTEXT       This project involves (check all that apply):  FORMCHECKBOX  Transgenic Plants or Animals (complete Part C)  FORMCHECKBOX  Pathogens: human, animal, or plant (complete Part D)  FORMCHECKBOX  Recombinant DNA (complete Part C)  FORMCHECKBOX  Arthropods (complete Part E)  FORMCHECKBOX  Biological toxins (complete Part F)  FORMCHECKBOX  Human or non-human primate body fluids, cell  FORMCHECKBOX  Vertebrate animals (describe in Narrative) lines, or tissues (complete Part G) Provide IACUC#  FORMTEXT        FORMCHECKBOX  My IACUC app. is dependent upon this approval. List all personnel involved with this project who may be at risk of potential exposure. Include lab technicians, workers autoclaving waste, animal care-takers, etc. List their job title and the date they completed Biosafety Training. HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/Biosafety_Training.pps"Training is available online at the EHS website or upon request from the Biosafety Officer. NameJob TitleDate Biosafety Training Complete  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Part B: Safety Equipment and Practices (to be completed for ALL registrations and renewals) Select the highest Biosafety Level (BSL) from each category (Laboratory, Animal, Plant, Arthropod) for this project: For more information on designating biological containment levels, refer to the  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/index.pdf" Biosafety Manual. Laboratory Animal Plant/Greenhouse Arthropod Containment Level (ACL)  FORMCHECKBOX  None  FORMCHECKBOX  None  FORMCHECKBOX  None  FORMCHECKBOX  None  FORMCHECKBOX  BSL-1  FORMCHECKBOX  Animal BSL-1  FORMCHECKBOX  BSL-1 Plant  FORMCHECKBOX  ACL-1  FORMCHECKBOX  BSL-2  FORMCHECKBOX  Animal BSL-2  FORMCHECKBOX  BSL-2 Plant  FORMCHECKBOX  ACL-2  FORMCHECKBOX  BSL-3  FORMCHECKBOX  Animal BSL-3  FORMCHECKBOX  BSL-3 Plant Personal Protective Equipment (PPE) to be used while conducting hazardous tasks in this registration (check all that apply):  FORMCHECKBOX  Gloves  FORMCHECKBOX  Eye protection  FORMCHECKBOX  Laboratory coat  FORMCHECKBOX  Solid front gown  FORMCHECKBOX  Other PPE (specify):  FORMTEXT       Safety Equipment readily available in laboratory of facility (check all that apply):  FORMCHECKBOX  Biological Safety Cabinet (BSC)  FORMCHECKBOX  Fume hood  FORMCHECKBOX  Eye wash  FORMCHECKBOX  Autoclave  FORMCHECKBOX  Handwashing sink (soap & paper towels)  FORMCHECKBOX  Drench hose or safety shower  FORMCHECKBOX  First aid kit Sharp instrument use and management:  FORMCHECKBOX  No sharps used  FORMCHECKBOX  Sharps are required (check all that apply):  FORMCHECKBOX  Sharps are contaminated with infectious materials  FORMCHECKBOX  Used sharps are discarded in a sharps container  FORMCHECKBOX  A written sharps use safety plan or SOPs are in place Decontamination and disinfection procedures in use (check all that apply and provide disinfectant info including contact time):  FORMCHECKBOX  Work surfaces and equipment are disinfected after (1) working, (2) at the end of each day, and (3) after spills. Chemical disinfectant and contact time:  FORMTEXT        FORMCHECKBOX  Liquid waste is disinfected prior to sewage disposal. Chemical disinfectant and contact time:  FORMTEXT        FORMCHECKBOX  Liquid and solid wastes are autoclaved before discard. Autoclave validation is performed with SteriGage Test Pack according to  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/index.pdf" Biosafety Manual. PI initials required: FORMTEXT        FORMCHECKBOX  An alternative validation to the Sterigage Test Pack procedure is performed; the protocol is attached. Procedures to be used in the event of a spill (refer to Biosafety Manual or your Exposure Control Plan). NOTE: Spills resulting in release or accidents involving recombinant DNA must be reported to the Biological Safety Officer in compliance with the NIH Guildelines. Describe spill response cleanup procedures for biohazardous materials:  FORMTEXT Allow aerosols to settle; wearing protective clothing; gently cover spill with paper towels and apply at least a 1:10 dilution of bleach to water, starting at perimeter and working towards the center; allow 30 minutes contact time.  Is an  HYPERLINK "http://www.ncsu.edu/ehs/www99/right/handsMan/worker/med.html" \l "access" occupational health surveillance program required (e.g. vaccinations, titers, etc.)?  FORMCHECKBOX  No occupational health surveillance program is required  FORMCHECKBOX  The following occupational health surveillance program is required:  FORMTEXT       Other comments:  FORMTEXT       Part C: Recombinant DNA (to be completed for rDNA research in organisms) Note: Use this section to register recombinant DNA in organisms (i.e. the joining of naturally occurring or synthetic DNA sequences (insert) to molecules cabable of replicating in a host cell (vector) and subsequent introduction of those constructs into living cells). PCR in the absence of molecular cloning is not registered. Is a deliberate attempt made to obtain expression of foreign gene(s) in the cloning vehicle?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If YES: What is the nature of the inserted sequences (payload) and original source of the DNA. Include organism of origin, gene or genes present if known, attach catalogue description if obtained commercially (e.g. E. coli - galactosidase driven by CMV-IE promoter, mus creatine kinase promotor driving duck myosin gene, synthetic hormone-responsive promotor drivingrat TGF):  FORMTEXT       Recipient organisms or cells to be used (cloning vehicle):  FORMCHECKBOX  Prokaryotes (e.g., E. coli K12):  FORMTEXT        FORMCHECKBOX  Eukaryotes (list specific cell lines):  FORMTEXT        FORMCHECKBOX  Higher animals (e.g., mice):  FORMTEXT       Animal Study Proposal#  FORMTEXT       (Attach a copy) Describe use of animals and  HYPERLINK "http://oba.od.nih.gov/oba/rac/guidelines_02/APPENDIX_Q.htm" \l "_Toc7256316" disposal practices: (if applicable)  FORMTEXT       Vectors to be used and source (e.g. pBR322 propagated in E. coli, adenoviruses E1A-Ad5 propagated in 293 cells):  FORMTEXT        FORMCHECKBOX  Virus is used. (check appropriate statement(s)): a) Quantity:  FORMCHECKBOX  Whole virus  FORMCHECKBOX  Greater than 2/3 viral genome  FORMCHECKBOX  Less than 2/3 viral genome b) Use:  FORMCHECKBOX  Vector  FORMCHECKBOX  Donor of genetic information Explain the function of the genetic material in this experiment:  FORMTEXT       c) Is virus replication competent?  FORMCHECKBOX YES  FORMCHECKBOX NO d) Is virus capable of infecting human cells?  FORMCHECKBOX YES  FORMCHECKBOX NO e) Classification:  FORMCHECKBOX  Prokaryotic virus Name:  FORMTEXT        FORMCHECKBOX  Eukaryotic virus Name:  FORMTEXT        FORMCHECKBOX  Oncogenic virus Name:  FORMTEXT       Risk level:  FORMCHECKBOX  High  FORMCHECKBOX  Moderate  FORMCHECKBOX  Low  FORMCHECKBOX  Infectious agent Name:  FORMTEXT        HYPERLINK "http://oba.od.nih.gov/oba/rac/guidelines_02/APPENDIX_B.htm" Risk level:  FORMCHECKBOX  RG1  FORMCHECKBOX  RG2  FORMCHECKBOX  RG3 f) Does the possibility of recombination with endogenous virus exist?  FORMCHECKBOX YES  FORMCHECKBOX  NO Does this project involve any of the following? Genetically modified microorganisms or genetic elements that contain nucleic acid sequences coding for any of the toxins listed on the  HYPERLINK "http://www.selectagents.gov/Select%20Agents%20and%20Toxins%20List.html" CDC List of Select Agents, or their toxin subunits?  FORMCHECKBOX  YES  FORMCHECKBOX NO Genetically modified microorganisms or genetic elements from organisms listed on the  HYPERLINK "http://www.selectagents.gov/Select%20Agents%20and%20Toxins%20List.html" CDC List of Select Agents shown to produce or encode for a factor associated with a disease?  FORMCHECKBOX  YES  FORMCHECKBOX NO Molecular cloning/expression of any toxic gene products?  FORMCHECKBOX YES  FORMCHECKBOX  NO Growth of cultures in volumes of 10 liters or greater at one time?  FORMCHECKBOX YES  FORMCHECKBOX  NO Release of recombinant organisms into the environment (if yes, describe in the Narrative)?  FORMCHECKBOX YES  FORMCHECKBOX  NO Transfer of antibiotic or other drug resistance to a pathogen, if doing so might compromise the use of the drug therapeutically? (Check yes only if this drug is used to treat human or animal infections caused by this organism.)  FORMCHECKBOX YES  FORMCHECKBOX  NO The construction or use of transgenic animals? (if yes, describe in the Narrative)  FORMCHECKBOX YES  FORMCHECKBOX  NO The construction or use of transgenic plants? (if yes, describe in Narrative)  FORMCHECKBOX YES  FORMCHECKBOX  NO Exposing plant or animal cells to the recombinant?  FORMCHECKBOX  YES  FORMCHECKBOX  NO a) If yes, describe the potential hazards:  FORMTEXT       b) If yes, list cells or cell lines to be used:  FORMTEXT       c) If yes, what infectious virus, oncogenic agents or toxins will be produced during this work?  FORMTEXT       Under what Sections(s) of the NIH Guidelines is this research classified? (attach  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/forms/Forma2.pdf" Classification Worksheet if necessary)  FORMTEXT       Part D: Biological Agents (microorganisms and biologically active agents not listed elsewhere) Note: duplicate this page as necessary for each agent. Name of Biological Agent:  FORMTEXT       Strain, Designation, :  FORMTEXT        HYPERLINK "http://oba.od.nih.gov/oba/rac/guidelines_02/APPENDIX_B.htm" Risk Group Classification:  FORMTEXT       Pathogen of:  FORMCHECKBOX  Human  FORMCHECKBOX Animal  FORMCHECKBOX Plant  FORMCHECKBOX None Signs/symptoms of human exposure (if applicable):  FORMTEXT       Is agent listed on the  HYPERLINK "http://www.selectagents.gov/Select%20Agents%20and%20Toxins%20List.html" CDC List of Select Agents?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is antibiotic resistance expressed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No other markers?  FORMTEXT       Is a toxin produced?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Work with toxin?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, also complete Part F Biological Toxins Scale of growth/culture of agent : (check only one):  FORMCHECKBOX  agent is not grown or cultured  FORMCHECKBOX  Diagnostic scale only (less than 10 Petri dishes or T-25 flask at a time  FORMCHECKBOX  Up to 1 liter volumes  FORMCHECKBOX  Between 1 and 10 liters  FORMCHECKBOX  Greater than 10 liter volume Is the organism concentrated/purified in viable form from cultures?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, method(s) of concentration:  FORMTEXT       Will open cultures or other materials be manipulated outside a BSC?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, describe measures to be used for the protection of personnel or the environemnt:  FORMTEXT       Have all personnel who will work with this agent (including those autoclaving or treating waste) received documented training describing routes of exposure, signs/symptoms of disease, treatments, and other pathogen-specific information?  FORMCHECKBOX  Not applicable -- not a known human pathogen  FORMCHECKBOX  Yes  FORMCHECKBOX  No For research using livestock animal or plant pathogens, do you have a current APHIS import or transport permit?  FORMCHECKBOX  Not applicable  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is organism inactivated according to procedures listed on Part B of this form?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If YES, skip to question 14. If "NO", indicate alternative decontamination and disinfection procedures (check all that apply):  FORMCHECKBOX  Work surfaces and /or equipment are disinfected with an effective chemical agent. Chemical disinfectant and contact time:  FORMTEXT        FORMCHECKBOX  Liquid waste is disinfected prior to sewage disposal. Chemical disinfectant and contact time:  FORMTEXT        FORMCHECKBOX  Liquid and solid wastes are autoclaved before discard. Autoclave validation is performed with SteriGage Test Pack according to  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/index.pdf" Biosafety Manual. PI initials required:  FORMTEXT        FORMCHECKBOX  An alternative validation to the SteriGage Test Pack procedure is performed; the protocol is attached. Will the organism(s) be used in animals?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If working with animals, is The "Animal Handling Medical Surveillance" in place?  FORMCHECKBOX  Yes  FORMCHECKBOX No Other comments:  FORMTEXT       Part E: Arthropods To be completed for all work with arthropods regardless of if they are known disease vectors. If the quesiton is not applicable to your research, type in  N/A or  Not Applicable . Genus and Species  FORMTEXT       Phenotype known to be rDNA modified, or insecticide resistant?:  FORMTEXT       Known to be free of specific pathogen(s)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 2.a. If Yes, which pathogen(s)?:  FORMTEXT       2.b. If No, the following should be considered: 2.b.1 Why would an infectious agent be suspected?  FORMTEXT       2.b.2 What route of transmission is indicated  FORMTEXT       2.b.3 Are agents that the arthropod transmits transmitted horizontally?  FORMTEXT       2.b.4 Are there reasons to believe that a novel or unknown agent is present?  FORMTEXT       2.b.5 What epidemiologic data are available?  FORMTEXT       2.b.6 What is the morbidity or mortality rate associated with the agent?  FORMTEXT       Is the arthropod species already established in the locale?  FORMTEXT       If the arthropod is exotic, explain the likelihood that the arthropod would become temporarily or permanently established in the event of accidental escape?  FORMTEXT       Are agents that the arthropod could reasonably be expected to transmit present in the locale or has the agent been present in the past?  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FORMTEXT       In the case of zoonotic diseases, does the animal reservoir exist in the locale, and, if so, what is its infection status?  FORMTEXT       Could the arthropod be controlled or locally eradicated by traditional methods (e.g. spraying, trapping) in the event of escape?  FORMTEXT       Is the arthropod derived from an exotic subpopulation (strain, geographically distinct form) whose phenotype is known or suspected to vary in ways that could reasonably be expected to significantly increase its vector competence?  FORMTEXT       If so, it should be handled under the more stringent conditions within Arthropod Containment Level 2 even if uninfected. Are disabled strains available whose viability after escape would be limited (e.g. eyecolor mutants, cold-sensitive)?  FORMTEXT       All life stages of the arthropod are inactivated by (check all that apply):  FORMCHECKBOX  Autoclave. Validation is performed with SteriGage Test Pack according to  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/index.pdf" Biosafety Manual. PI initials required:  FORMTEXT        FORMCHECKBOX  An alternative validation to the SteriGage Test Pack procedure is performed; the protocol is attached.  FORMCHECKBOX  An alternative to autoclaving is performed (freezing, chemical). The protocol and validation procedure is attached. Other comments:  FORMTEXT       Part F: Biological Toxins Toxin(s):  FORMTEXT       Subtype(s):  FORMTEXT       Is toxin listed on the  HYPERLINK "http://www.selectagents.gov/Select%20Agents%20and%20Toxins%20List.html" CDC List of Select Agents?  FORMCHECKBOX  Yes  FORMCHECKBOX  No LD50:  FORMTEXT       for  FORMCHECKBOX  humans  FORMCHECKBOX  rodents  FORMCHECKBOX  other vertebrate animal Amount of toxin used in a single experiment:  FORMTEXT       Total inventory of toxin:  FORMTEXT       Chemical/disinfectant used for inactivation and contact time:  FORMTEXT       Signs/symptoms of human exposure:  FORMTEXT       Part G: Human or Non-Human-Primate Derived Material (to be completed for research using human or non-human primate blood, body fluids, cell lines, or unfixed tissues) Identify samples to be manipulated (check all that apply):  FORMCHECKBOX  Human  FORMCHECKBOX  Non-human primate  FORMCHECKBOX  Whole blood/serum:  FORMTEXT        FORMCHECKBOX  Established cell lines:  FORMTEXT        FORMCHECKBOX  Blood component:  FORMTEXT        FORMCHECKBOX  Unfixed tissues:  FORMTEXT        FORMCHECKBOX  Cell "strains :  FORMTEXT        FORMCHECKBOX  Other (identify):  FORMTEXT        FORMCHECKBOX  Tissue from animals infected with HIV or HBV Cell lines or repository cells infected with HIV/HBV:  FORMTEXT       If using cell lines, list source (e.g. ATCC # if known)  FORMTEXT         HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/BBP.htm" OSHA BLOODBORNE PATHOGENS STANDARD REQUIREMENTS Are all personnel working with this material identified on an  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/BBP.htm" Exposure Control Plan?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have all personnel working with this material received or declined in writing the  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/BBP.htm" hepatitis B vaccine?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have all personnel working on this project received  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/BBP.htm" bloodborne pathogen training within one year?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Has this project been reviewed by the Institutional Review Board (IRB)?  FORMCHECKBOX  N/A  FORMCHECKBOX  review in progress  FORMCHECKBOX  Yes  FORMCHECKBOX  No Is this biohazard waste inactivated according to procedures listed on Part B of this form?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If "NO", indicate alternative decontamination and disinfection procedures (check all that apply):  FORMCHECKBOX  Work surfaces and /or equipment are disinfected with an effective chemical agent. Chemical disinfectant and contact time:  FORMTEXT        FORMCHECKBOX  Liquid waste is disinfected prior to sewage disposal. Chemical disinfectant and contact time:  FORMTEXT        FORMCHECKBOX  Liquid and solid waste is autoclaved before discard. Autoclave validation is performed with SteriGage Test Pack according to  HYPERLINK "http://www.ncsu.edu/ncsu/ehs/www99/left/bioSafe/index.pdf" Biosafety Manual. PI initials required:  FORMTEXT        FORMCHECKBOX  An alternative validation to the SteriGage Test Pack procedure is performed; the protocol is attached. Part H: Biosafety Narrative Attach a brief but complete Narrative of the proposed research that addresses: the goals/purpose of the research, the experimental methods to be used in the study, safety and containment precautions to be used during the conduct of research, and a brief description of the facilities where the study will take place. The Narrative must address the potential sources of risk to personnel and/or the environment (e.g., pollen or interbreeding with wild species), and how those risks will be managed. Do not attach a grant proposal abstract or an IACUC form as your research narrative, as these do not include all the information requested above. Use this space to type or paste the Biosafety Narrative or attach as necessary: ( FORMTEXT       Acknowledgement of Principal Investigator -- check all boxes that apply to this research, complete the dual-use statements, then sign below.  FORMCHECKBOX  Part C: Recombinant DNA. As the Principal Investigator for this protocol, I understand and acknowledge my responsibilities under the NIH Guidelines. I accept responsibility for the safe use of all recombinant organisms at the established Biosafety Level and have informed all personnel of the risks of exposures while working with these materials.  FORMCHECKBOX  Part D: Biological agents not listed elsewhere. I am familiar with and agree to abide by the provisions of the current CDC/NIH  Biosafety in Microbiological and Biomedical Laboratories as well as NC State's biosafety policies and procedures. I will assure that research personnel are trained in standard microbiological practices and techniques required to ensure safety for this project, emergency response procedures, exposure incident response procedures, and waste management procedures.  FORMCHECKBOX  Part E: Arthropods. I accept responsibility for the safe use of arthropods and agree to follow the safety and containment requirements to be established by the IBC.  FORMCHECKBOX  Part F: Biological Toxins. I will assure that research personnel are trained in chemical safety techniques and standard microbiological practices required to ensure safety for this project, as outlined in Appendix I--Guidelines for Work with Toxins of Biological Origin of the CDC/NIH Biosafety in Microbiological and Biomedical Laboratories as well as NC State's biosafety policies and procedures.  FORMCHECKBOX  Part G: Human or Non-Human-Primate derived material. I accept responsibility for the safe use of human blood, body fluids, cell lines, or tissues as prescribed in the OSHA Bloodborne Pathogen Standard and agree to follow Biosafety Level 2 practices and procedures while working with these materials. All personnel have received training in the Exposure Control Plan specific to this laboratory or department. I understand that certain types of experiments could be considered  of dual use concern. (Refer to the SERCEB training for more information at  HYPERLINK "http://www.serceb.org/dualuse.htm" http://www.serceb.org/dualuse.htm ). Therefore I attest that this research may  FORMCHECKBOX YES  FORMCHECKBOX  NO Enhance the harmful consequences of a biological agent or toxin;  FORMCHECKBOX YES  FORMCHECKBOX  NO Disrupt the immunity or the effectiveness of an immunization without clinical and/or agricultural justification;  FORMCHECKBOX YES  FORMCHECKBOX  NO Confer to a biological agent or toxin, resistance to clinically and/or agriculturally useful prophylactic or therapeutic interventions against that agent or toxin or facilitate their ability to evade detection methodologies;  FORMCHECKBOX YES  FORMCHECKBOX  NO Increase the stability, transmissibility, or the ability to disseminate a biological agent or toxin;  FORMCHECKBOX YES  FORMCHECKBOX  NO Alter the host range or tropism of a biological agent or toxin;  FORMCHECKBOX YES  FORMCHECKBOX  NO Enhance the susceptibility of a host population; or  FORMCHECKBOX YES  FORMCHECKBOX  NO Generate a novel pathogenic agent or toxin or reconstitute an eradicated or extinct biological agent. The information contained in this application is accurate and complete. I understand that incomplete fields, an incomplete Biosafety Narrative, or inaccurate information may result in significant delays in the processing of this registration. Signature- Principal Investigator Date Return the signed registration to the Biological Safety Officer, Environmental Health & Safety, Campus Box 8007 or email Biological Safety Officer at  HYPERLINK "mailto:darren_treml@ncsu.edu" darren_treml@ncsu.edu. Approval of IBC Chair The Institutional Biosafety Committee has reviewed the proposed project and has approved the use of these research materials using the containment facilities and practices outlined based on the guidelines of the CDC/NIH  Biosafety in Microbiological and Biomedical Laboratories . 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