Fillable Biosafety Protocol Amendment (Wright State University)

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Biosafety Protocol Amendment (Wright State University)

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Biosafety Protocol Amendment
Wright State University
Research and Sponsored Programs
This application contains proprietary/confidential information (Please attach a justification
statement and any relevant documentation).
IBC No.
Associated AUP#
Associated IRB#
Title:
Principal Investigator
Biosafety Officer
Current Project Information
Amendment Type
What type of change is requested? (check all that apply)
Personnel
Procedure
Biohazardous agent Biosafety level
Animal use Human subject use
Project Location (from/to):
Other:
What is the current level of biocontainment?
BSL-1
BSL-2
BSL-2+
BSL-3
Is the current project exempt from the NIH Guidelines?
Yes
No
I have reviewed this amendment and found it to be suitable for IBC review:
(Signature
and date of
Biosafety
O
fficer)
Principal Investigator Name:
Title:
WSU username (e.g. w001xyz):
Department:
Address:
Phone/Fax:
Email:
Statement of Responsibility: I accept responsibility for the safe conduct of work with the agents
described in this application. The information in this application is accurate and complete.
(Signature
and date of Principal In
vestigator)
For BSO use only:
Amendment No.:
Date
Received:
Page 1 of 2
RSP Biosafety Protocol Amendment (Version 02/17/2017)
Associated RS#
Submit to BSO
click to sign
signature
click to edit
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signature
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PI Name:
List NEW Personnel Only (use additional sheet if necessary)
1. Name:
username:
Title:
BBP Date:
Lab Safety Date:
Signature:
Date:
Contact:
2. Name:
username:
Title:
BBP Date:
Lab Safety Date:
Signature:
Date:
Contact:
3. Name:
username:
Title:
BBP Training Date:
Lab Safety Date:
Signature:
Date:
Contact:
4. Name:
username:
Title:
BBP Date:
Lab Safety Date:
Signature:
Date:
Contact:
5. Name:
username:
Title:
BBP Date:
Lab Safety Date:
Signature:
Date:
Contact:
Do any of the above personnel additions represent a change in leadership?
Yes
No
If yes, please explain in narrative.
Narrative Section. Please provide a complete description of the protocol change. Include enough
detail to allow for an accurate risk assessment (similar to the types of information requested on the
original application). Amendments with insufficient information may cause delays in the review
process. Attach additional sheets as necessary.
Page 2 of 2
RSP Biosafety Protocol Amendment (Version 02/17/2017)
Save and Rename form to email to Personnel for their signatures.
Decribe personnel removals in the Narrative Section below.
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signature
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signature
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signature
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signature
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signature
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Biosafety Protocol Amendment (Wright State University)

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Completed 16 December 2020

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