SEAWATER RESEARCH LABORATORY
BSL-3 Laboratory Usage Request Form
Submitter:
Name
Email:
Principal Investigator(s):
Banner Index:
Pathogen(s)
Pathogen(s) to be used:
Does this pathogen(s) currently exist on the department of Homeland Security or USDA Select Agents and Toxins list?
Yes
No
NA
Target host organism:
Known symptoms in humans:
Methods of treatment and their efficacy:
Method of Challenge:
Intraperetoneal
Subcutaneous Injection
Intravenous Injection
Intramuscular Injection
Static Bath
Ingestion
Other
NA
Antibiotics or Antimicrobials
Will any antibiotics or other antimicrobials be utilized during the trial?
Yes
No
NA
If yes, list compound(s):
Method of administering the compound:
Injection
Static Bath
Ingestion
Other
NA
Personnel
Has the appropriate safety equipment been ordered for all authorized personnel?
Yes
No
NA
Authorized personnel:
Have all personnel had their initial health scan and titer?
Yes
No
NA
Have all personnel been issued their exposure cards and have their ID cards been coded for BSL-3 access?
Yes
No
Pending
NA
Have all personnel had the following received training inthe following areas:
Basic Lab Safety:
Basic Microbiological Practices:
BSL-3 Safety and Operation:
Safety Equipment Operation
:
Mask Fit Verification:
Authorizations
Has the project been approved by the IBC Committee?
Yes
No
NA
Has the project been approved by the IACUC Committee?
Yes
No
NA
Has the SRL Usage Request Form been submitted?
Yes
No
NA
Submitted with this form.
