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FORM APPROVED: REQUEST TO TRANSFER Submit completed form (Department of Health and Human Services)

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REQUEST TO TRANSFER
SELECT AGENTS AND TOXINS
(APHIS/CDC FORM 2)
FORM APPROVED
OMB NO. 0579-0213
OMB NO. 0920-0578
EXP DATE 10/31/2020
Detailed instructions are available at http://www.selectagents.gov/form2.html. Answer all items completely and type or print in
ink. This request must be signed and submitted to either APHIS or CDC:
Animal and Plant Health Inspection Service
Agriculture Select Agent Services
4700 River Road Unit 2, Mailstop 22, Cubicle 1A07
Riverdale, MD 20737
FAX: (301) 734-3652
E-mail: cdcform2@cdc.gov
Centers for Disease Control and Prevention
Division of Select Agents and Toxins
1600 Clifton Road NE, Mailstop A-46
Atlanta, GA 30329
FAX: (404) 471-8468
E-mail: cdcform2@cdc.gov
Accession Number:
Transfer ID Number:
(For Program Use ONLY)
Submit completed form only once by either e-mail, fax, or mail
APHIS/CDC AUTHORIZATION NUMBER: ______________________ EXPIRATION DATE: _________________________
SECTION 1 – TO BE COMPLETED BY RECIPIENT
SECTION A – RECIPIENT INFORMATION
1. Entity name: 2. Entity registration number:
3. Address (NOT a post office address): 4. City: 5. State: 6. Zip code:
7. Principal Investigator name:
First:
MI:
Last:
8. APHIS Permit #:
9. Responsible Official (RO) name:
First:
MI:
Last:
10. RO telephone #:
11. RO fax #: 12. RO e-mail address:
SECTION B – SENDER INFORMATION
13. Entity name: 14.
Entity registration number:
______________________________
Clinical/diagnostic laboratory
Other:
_______________________________________
15. Address (NOT a post office address): 16. City: 17. State: 18. Zip code: 19. Country:
20. Responsible Official (RO) or facility director:
First: MI: Last:
21. RO/Facility Director telephone #:
22. RO/Facility Director fax #: 23. RO/Facility Director e-mail address:
24. This transfer request is for a select agent or toxin that was identified in a clinical or diagnostic sample:
Yes
No
If yes, please ensure that an APHIS/CDC Form 4 “Report of the Identification of a Select Agent or Toxin” is submitted to APHIS or CDC within 7 calendar days.
25. Is the agent a product of a restricted experiment, as defined in section 13 of the select agent regulations? If yes, provide the description used in the Federal
Select Agent Program approval letter for the restricted experiment that produced the agent. Yes No
SECTION C – LIST OF SELECT AGENTS AND TOXINS REQUESTED (attach additional sheets if necessary)
26. Select agents and/or toxins to be transferred:
A
B
C
D
E
I hereby certify that the information contained in Section 1 on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false
statement on any part of this form, or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR Part 331, 9
CFR Part 121, or 42 CFR Part 73 may result in civil or criminal penalties, including imprisonment.
Signature of Responsible Official: _________________________________________________ Title: ____________________________________
Typed or printed name of Responsible Official: _______________________________________ Date: ____________________________________
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REQUEST TO TRANSFER
SELECT AGENTS AND TOXINS
(APHIS/CDC FORM 2)
FORM APPROVED
OMB NO. 0579-0213
OMB NO. 0920-0578
EXP DATE 10/31/2020
Detailed instructions are available at http://www.selectagents.gov/form2.html. Answer all items completely and type or print in
ink. This form must be signed and submitted to either APHIS or CDC:
Animal and Plant Health Inspection Service
Agriculture Select Agent Services
4700 River Road Unit 2, Mailstop 22, Cubicle 1A07
Riverdale, MD 20737
FAX: (301) 734-3652
E-mail: cdcform2@cdc.gov
Centers for Disease Control and Prevention
Division of Select Agents and Toxins
1600 Clifton Road NE, Mailstop A-46
Atlanta, GA 30329
FAX: (404) 471-8468
E-mail: cdcform2@cdc.gov
Accession Number:
Transfer ID Number:
(For Program Use ONLY)
Submit completed form only once by either e-mail, fax, or mail
APHIS/CDC AUTHORIZATION NUMBER: ______________________ EXPIRATION DATE: _________________________
SECTION 2 – TO BE COMPLETED BY SENDER
SECTION D – LIST OF SELECT AGENTS AND TOXINS SHIPPED (attach additional sheets if necessary)
27. Select agents and/or toxins: 28.
Characterization
of agent:
29. Number
of items
(e.g., vial,
slant, plant,
etc.):
30. Form
(powder/liquid/
slant):
31. Total volume or
weight of item contents
(e.g., mL, mg, ng):
A
B
C
D
E
SECTION E – RECIPIENT NOTIFICATION INFORMATION
32. Name of individual at recipient entity notified of expected shipment:
First:
MI:
Last:
33. Date of notification: 34. Type of notification:
E-mail
Fax
Telephone
SECTION F – SHIPPING INFORMATION
35. Name of individual who packaged shipment:
First:
MI:
Last:
36. Number of packages shipped:
37. Shipment date:
38. Package description (size, shape, description of packaging including number and type of inner packages):
39. Name of carrier (If hand-delivered, please provide name of individual): 40. Airway bill number/bill of lading number/tracking number:
I hereby certify that the select agents and/or toxins were packaged, labeled, and shipped in accordance with all federal and international regulations and information
contained in Section 2 of this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false statement on any part of this form,
or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR Part 331, 9 CFR Part 121, or 42 CFR Part 73
may result in civil or criminal penalties, including imprisonment.
Signature of Sender: ____________________________________________________________ Title: _______________________________________________
Typed or printed name of Sender: ___________________________________________________________ Date: _____________________________________
SECTION 3 – TO BE COMPLETED BY RECIPIENT
(Within 2 days of transfer receipt as defined in Section 16 2(h) of the Select Agent Regulations)
41. Name of individual who received shipment:
First:
MI:
Last:
42.
Transfer did not occur
Transfer occurred/date of receipt:
43. The agents/toxins listed in Section 2 were received:
Yes
If no, explain discrepancy in separate attachment.
44. Shipment was packaged, labeled, and shipped in accordance with
regulations:
Yes
If no, explain discrepancy in separate attachment.
I hereby certify that the information contained in Section 3 on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false
statement on any part of this form, or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR Part 331, 9
CFR Part 121, or 42 CFR Part 73 may result in civil or criminal penalties, including imprisonment.
Signature of Responsible Official: __________________________________________________ Title: _______________________________________________
Typed or printed name of Responsible Official: _________________________________________________ Date: ______________________________________
Public reporting burden: Public reporting burden of this collection of information is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0576).
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FORM APPROVED: REQUEST TO TRANSFER Submit completed form (Department of Health and Human Services)

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Completed 19 July 2020

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