TYPES
OF BIOHAZARDOUS MATERIALS USED
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Last Name:
(Principal Investigator)
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First Name:
(Principal Investigator)
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Middle Initial:
(Principal Investigator)
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| Degree (check all that
apply)
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Ph.D.
M.D. D.V.M.
D.S. Pharm.D
Other:
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| Department:
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| Building:
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| Room #
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INVENTORY
OF BIOHAZARDOUS WORK ENVIRONMENTS
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| Yes
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No
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Work With:
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BACTERIA FUNGI,
VIRUSES, AND PARASITES AT BIOSAFETY LEVEL 1
Organisms that are well characterized and not known to cause disease in healthy
adults.
List genus and species:
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BACTERIA, FUNGI, VIRUSES,
PARASITES, RICKETTSIA AT BIOSAFETY LEVEL 2, 3, OR 4
Can cause disease in healthy adults. A list of these agents can be found in
Appendix B of Biosafety Process Manual.
List genus and species:
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HUMAN BLOOD AND BODY FLUIDS
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CELLS OR TISSUE, NON-PRIMATE
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CELLS OR TISSUE, HUMAN OR PRIMATE
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HUMAN GENE THERAPY
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ONCOGENIC VIRUSES
List viruses
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RECOMBINANT DNA MOLECULES
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SELECT
AGENT
(Bacteria, Fungi, Viruses, Rickettsia, Toxins,
Recombinant DNA Prions)
List agent(s):
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WILL USE INVOLVE A CLINICAL
SETTING OR HUMAN SUBJECTS?
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| Yes
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No
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Does Your Work Area Have A:
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BIOLOGICAL SAFETY CABINET?
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CENTRIFUGE?
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AUTOCLAVE?
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| Yes
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No
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Do you ship materials
that are classified as diagnostic, research, or biological?
If yes, how many shipments per year?
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Any
additional explanatory comments?
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| Print
a copy of the displayed form for your departmental records and then choose
submit below.
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