Fillable Biosafety Disclosure Form (Medical College of Wisconsin)

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Biosafety Disclosure Form (Medical College of Wisconsin)

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The Biosafety Disclosure Form (Medical College of Wisconsin) form is 4 pages long and contains:

  • 1 signature
  • 28 check-boxes
  • 33 other fields

Country of origin: US
File type: PDF

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BROWSE MEDICAL COLLEGE OF WISCONSIN FORMS

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Yes No
Is this cell type tested for human pathogens?
Yes No
Yes No
Is this cell type tested for human pathogens?
Yes No
Yes No
If "Yes": Lentivirus
Adenovirus
AAV
MicroRNA
Other
Cell Type(s)
Cell Type(s)
Clinical Sample?
Cells adherent/primary culture?
Describe method and generation of rDNA/viral vector as well as any special precautions that needs to be taken:
MCW Cancer Center Redox &
Bioenergetics Shared Resource (CCRBSR)
Biosafety Disclosure Form
Office Use Only
Mouse
Rat
Sample Description
BSL-1
BSL-2
Human
Non-Human Primate
rDNA/Transformed with Viral Vector?
Human Blood Products
Microorgainism
Protein/Peptide/Liposome
Other
Purified Cell Extracts
Yes No
Yes No
Use of Any Hazardous Chemicals?
If "Yes" list chemicals as well as any special precautions that need to be taken. Designate where and who will be
handling these chemicals. Safety Data Sheets (SDS) for each chemical used need to be provided. Please check to see if
your agent is a particularly hazardous substance. http://infoscope.mcw.edu/SafetyCommittees/HazChem.htm
Infected with Pathogen or Infectious Agent?
If "Yes" list pathogen(s) and/or infectious agent(s) as well as any special precautions that needs to be taken:
TheMCW Cancer Center Redox & Bioenergetics Shared Resource (CCBSR) provides expertise in cellular metabolism
analysis. A diverse range of samples from multiple users are analyzed, including potentially infectious materials. This
form needs to be accurately filled out so we know how to safely process your sample. We use the Biosafety in
Microbiological & Biomedical Laboratories (BMBL) as a guide to perform the risk assessment on your sample. Your
cooperation in providing the above information is greatly appreciated so that we are able to safely process your
sample in a timely manner. Once approved, samples in closed containers transported in secondary containment may
be submitted for analysis.
Name
Phone
Fax
Email
Institution
Department
Date
Title
IBC Protocol #
Approval Date
IBC Title
Approval Letter
Other Lab Contact(s)
Phone/Email
Administrative Information
Please provide a description of the goals of your proposed experiment.
Please indicate any sample processing steps that will be performed in the Center other than routine instrument
analysis of already processed samples (e.g. sample resuspension, dilution, centrifugation).
Project Information
Principal Investigator (PI):
Principle Investigators are responsible for accurate disclosure of sample information. Approval is required PRIOR to
sample submission to the center to allow for the necessary safety precautions. Biosafety Disclosure Forms will be
evaluated promptly upon receipt to prevent delay of experimentation. Additional documentation may be requested
prior to sample approval. Please contact Monika Zielonka, at 414-955-4059 in room MFRC 2013 with any questions
regarding this form.
Signature of Principle Investigator
Date
I have carefully read the Biosafety Disclosure Form and certify the information provided to be correct.
Principle Investigator Disclosure Information
Please indicate any sample processing steps that will be performed in the Center other than routine instrument
analysis of already processed samples (e.g. sample resuspension, dilution, centrifugation).
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Biosafety Disclosure Form (Medical College of Wisconsin)

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Completed 23 July 2020

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