Safety Nomination Form

Quick Links
	Fact Sheets
	Forms
	Guides
	Training
	Waste Disposal

CEHS Sections
	Enviro Compliance
	Lab & Haz Waste
		Biological
		Chemical
	Occ Health/Safety
	Radiation Safety
__
CEHS Information
	About CEHS
	Awards
	Feedback
	Links
	News
	Safety Committees
	Search
	Staff Directory

Lost? Use the

CEHS, Center for Environmental Health and Safety

Inventory Questionnaire for Select Agents
[Includes Agents and Toxins of Biological Origin]

Following you will find a web form for Select Agents that we urgently need your cooperation in completing. The form is intended to assist the Center for Environmental Health and Safety and the Institutional Biosafety Committee in meeting obligations applicable to the safety of laboratory employees, students and visitors. Also of importance is our ability to demonstrate University compliance with regulations, guidelines and recommendations of the Centers for Disease Control and Prevention (CDC) of the Department of Health and Human Services (DHHS), as well as the Occupational Safety & Health Administration (OSHA). The signing into law of The Patriot Act recently, and additional legislation that is likely, makes collection of this information even more critical. The attached questionnaire addresses Select Agents which are agents of biological origin. Questions regarding other chemical agents which are not biological in nature will be addressed in a future questionnaire listing these agents. Additionally, this form must be completed any time procedures change and/or additional select agents are added to inventory.

Sections I, II and IV must be completed by every laboratory. Section III must be completed by any laboratory containing select agents.

NOTE: Please also review the December, 2001 "Research Matters" Cover Story.

Section I. (General Information)

Location
Principal Investigator
Department
Building
Room Number
Phone Number
Email Address

Section II. (Select Agents)

Department of Health and Human Services Regulated Biological Agents
(Please check all that apply. If none, please check the box indicating none. Note, you must check at least one box.)

Viruses

Crimean-Congo hemorrhagic fever virus
Eastern Equine Encephalitis virus
Ebola viruses
Equine Morbillivirus
Lassa fever virus
Marburg virus
Rift Valley fever virus
South American Hemorrhagic fever viruses
Junin
Machupo
Sabia
Flexal
Guanarito
Tick-borne encephalitis complex viruses
Variola major virus (Smallpox virus)
Venezuelan Equine Encephalitis virus
Viruses causing hantavirus pulmonary syndrome
Yellow fever virus

Bacteria

Bacillus anthracis
Brucella abortus, B. melitensis, B. suis
Burkholderia (Pseudomonas) mallei
Burkholderia (Pseudomonas) pseudomallei
Clostridium botulinum
Francisella tularensis
Yersinia pestis

Rickettsiae

Coxiella burnetii
Rickettsia prowazekii
Rickettsia rickettsii

Fungi

Coccidioides immitis

Toxins

Abrin
Aflatoxins
Botulinum toxins
Clostridium perfringens epsilon toxin
Conotoxins
Diacetoxyscirpenol
Ricin
Saxitoxin
Shigatoxin
Staphylococcal enterotoxins
Tetrodotoxin
T-2 toxin

Recombinant Organisms/Molecules

Genetically modified microorganisms or genetic elements from organisms listed in Section II., shown to produce or encode for a factor associated with a disease.

Genetically modified microorganisms or genetic elements that contain nucleic acid sequences coding from any of the toxins listed in Section II., or their toxic subunits.

None

None of the above agents. (If this box is checked, skip to "Individual Completing This Form").

Section III. (Select Agent Use)

Source of the agent(s) if from a source outside the University

Do you intend to transfer agent(s) to a recipient outside of the University?
No
Yes; specify:

List the room numbers of all laboratories in which the agent(s) specified above are stored, cultured, manipulated, or treated (include all culture rooms/cold rooms/common equipment rooms):

Building Name
Room Number
Type of Room/Functions Performed

For the select agents, provide the following, if applicable: [note: list the amount (titer/volume/unit) in active use and/or the quantity stored and the number of units (e.g., 106cfu/ml/1ml microcentrifuge tube with a total of 25 microcentrifuge tubes in use or stored)].

Amount in use (e.g., titer/volume/unit, no. units)
Amount in storage (e.g., titer/volume/unit, no. units)
Security-How stored (e.g. stored in –70 C locked freezer)

Please list information for each individual with regards to each select agent, separately.

Names of individuals who have Access for each select agent
Are the aforementioned all US citizens?	Yes No
Requirements for access (e.g., key, key card, push button code, other)
Describe Disposal process

Section IV. (Certification)

Individual completing this questionnaire

Name
Title
Phone Number
Email Address

Principal Investigator Review
(I have prepared and/or reviewed this questionnaire. As completed, it accurately indicates my research use of Select Agents in my laboratory(s).)

Name
Title
Phone Number

Copyright © 1994-2003 Southern Illinois University
Center for Environmental Health and Safety
Phone: 618-453-7180
E-mail: info@cehs.siu.edu