University of Guelph
Agreement on Biosafety
Name: ____________________________________________________ Date: _________________
Principal Investigator: __________________________________________________________________
Version 2 January 26, 2017 Page 1
I have read and will comply with the University of Guelph’s Biosafety Policy.
I will work in accordance with the University of Guelph’s Biosafety program, Canadian Biosafety
Standard and any other applicable legislation, including conditions of the Biohazard Permit.
Yes
I have been trained on the use of and know the exact location of the eyewash, safety shower, fire exit,
spill kit and first aid kits.
Yes
I have been fully trained on the specifics of my work and am confident to start performing such work. I
have been informed of the risks associated with this work. I have read all applicable Safety Data Sheets
and Pathogen Safety Data Sheets.
Yes
I will notify my supervisor or their designate, and the Biosafety Officer, of any incident or exposure,
and will also complete the required Illness or Injury Incident Report :
https://www.uoguelph.ca/hr/system/files/IR%20-%20A14.pdf
Yes
I will notify my supervisor or their designate, and the Biosafety Officer, of any violations of safety
requirements, or any inadvertent release of biohazardous materials to the environment. I will
cooperate fully in any investigation of these matters.
Yes
I will wear required Personal Protective Equipment, including footwear with closed toes and heels, and
be fit-tested as required by EHS if respiratory personal protective equipment is used.
Yes
I know that as an individual handling potentially hazardous biological substances (animals, plants,
bacteria, fungi, viruses, toxins, etc.), I may be exposed to agents that can affect my health. If I have or
have had one of the following medical conditions, I will contact Occupational Health and Wellness at
ext. 52647 to make an appointment to meet with the Occupational Health Nurse/Physician.
1. Cancer of any kind
2. HIV-positive status
3. Diabetes
4. Taking oral steroid therapy
5. On immunosuppressive treatment
6. Severe allergic reactions
7. Any medical condition that may be impacted by working with biohazardous materials,
e.g. pregnancy, splenectomy, chronic lung disease, eczema.
If I should develop any of the above conditions, I will notify Occupational Health and Wellness
immediately, at (519) 824-4120, ext. 52647. If I transfer to another biohazard permit, I will again notify
Occupational Health and Wellness.
Yes
I recognize my responsibility to observe these practices and precautions while present in the
laboratory and understand their importance for the safety and welfare of myself, all others in the
laboratory, and the environment.
Yes
There may be some instances whereby vaccinations are recommended for the materials handled. This
includes but is not limited to work with untreated (raw) sewage and human blood, body fluids, tissues
or cell lines. I have been advised of any immunizations recommended for work with this agent(s).
Yes
University of Guelph
Agreement on Biosafety
Name: ____________________________________________________ Date: _________________
Principal Investigator: __________________________________________________________________
Version 2 January 26, 2017 Page 2
Certification:
I recognize my responsibility to observe these practices and precautions while present in the laboratory
and understand their importance for the safety and welfare of myself, all others in the laboratory, and
the environment.
____________________________ ____________________________
Signature of Individual Signature of Principal Investigator
____________________________ ____________________________
Print Name Print Name
Date________________________ Date________________________
Attention: Biosafety Principal Investigators (Permit Holders)
Please submit a signed copy of this form for each investigative staff
member listed in your Biohazard permit application, including yourself,
along with your Biohazard Permit application.
The original of this agreement, must be kept in your office/lab.
Note that your records may be audited during a lab inspection.
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