OFFICE FOR RESEARCH USE ONLY
DATE RECEIVED OR REVISED:
*ONLY TYPED FORMS WILL BE ACCEPTED*
If this protocol is a resubmission, which protocol(s) is it intended to replace: Old IBC Protocol No.(s):
DATE APPLICATION COMPLETED: IBC No. (Will be assigned initially by IBC office):
2. PRINCIPAL INVESTIGATOR:
Campus OR Work Phone Number:
Department Affiliation: Mailing Address
1
: Choose One, if Applicable:
New Address - Change for all other
active protocols
E-mail Address (use ISU email
if ISU employee or student):
For on campus investigators use Department and Mail Code. For off campus investigators provide complete mailing address.
3. PERSONNEL for CORRESPONDENCE: List personnel below who should be copied on the correspondence.
Name (Last, First): Name (Last, First): Name (Last, First):
Campus or Work Phone Number: Campus or Work Phone Number: Campus or Work Phone Number:
Department Affiliation: Department Affiliation: Department Affiliation:
E-mail Address (use ISU email if ISU employee
or student)
:
E-mail Address (use ISU email if ISU
employee or student)
:
E-mail Address (use ISU email if ISU
employee or student)
:
Mailing Address
: Mailing Address
: Mailing Address
:
Choose One, if Applicable:
New Address - Change for all protocols
Choose One, if Applicable:
New Address - Change for all protocols
Choose One, if Applicable:
New Address - Change for all protocols
Research Coordinator (Not Directly
Involved with rDNA/IA)
Research Coordinator (Not Directly
Involved with rDNA/IA)
Research Coordinator (Not Directly
Involved with rDNA/IA)
ALL personnel who work directly with rDNA, synthetic DNA, or infectious agents
must be listed in Personnel Section (VII).
FORM A - Protocol for Use of
Recombinant or Synthetic Nucleic
Acid Molecules in Research
Version 1.0
Idaho State University, Office for Research
Institutional Biosafety Committee (IBC)
1651 Alvin Ricken Drive, Pocatello, ID 83201-8046
Phone: 208-282-2179 Fax: 208-282-4723
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