Fillable Registration Form Recombinant DNA Research (University of Memphis)

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Registration Form Recombinant DNA Research (University of Memphis)

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Registration Form
Recombinant DNA Research
IMPORTANT: This registration form is based on the NIH “Guidelines for Research Involving Recombinant DNA
Molecules,” and will become an official record of your activities. Please review the guidelines prior to filling out
this form. To view the most recent edition of these guidelines, please visit the EH&S Biological Safety website
.
Principal Investigator:
Department:
Campus Mailing Address:
Building and Room number where the project will take place:
Office Phone number: Laboratory Phone number:
Project Title:
Project Period: to Granting Agency:
1. Where is this project being carried out?
Laboratory Greenhouse/Animal Facility Environmental Release
(Please attach USDA application/permit)
2. Which of the following six categories apply to the proposed project? (Select one)
III-A; Experiments that require IBC Approval, RAC Review, and NIH Director Approval before initiation
III-B; Experiments that require NIH/ORDA and IBC Approval before initiation
III-C; Experiments that require IBC and Institutional Review Board approval and NIH/ORDA
Registration before initiation
III-D; Experiments that require IBC Approval before initiation
III-E; Experiments that require IBC Notification simultaneous with initiation
III-F; Exempt Experiments (no registration required)
3. Which le
vel of containment applies to the proposed project? (Select one from each category)
Biosafety Level: 1 2 3
N/A
Animal Biosafety Level: 1 2 3
N/A
Plant Biosafety Level: 1 2 3
N/A
4. Will this project require large-scale fermentation (> 10 liters) of organisms
containing recombinant DNA molecules?
Yes No
5. Will this project at some point require the release of organisms containing
recombinant molecules into the environment?
Yes No
6. Will this project involve the use of transgenic plant or animal species?
Yes
No
7. Will there be any attempt to transfer recombinant DNA molecules in vivo to
plant or animal systems (other than tissue culture)?
Yes No
Recombinant DNA Research Form Page 1 of 3 Updated May 2016
PLEASE TYPE! Remember, this form will become an official record of your activities!
Registration From
Recombinant DNA Research
8. Recombinant DNA experiment/project details:
a. Host strain(s) used
(include genus, species, and parent strains):
b. Sou
rce of DNA/RNA sequences
(include genus and species, and gene name, abbreviation, and function):
c. Reco
mbinant plasmid(s)/vector(s) used:
d. Will there be any attempt to obtain expression of the foreign gene? Yes No
If yes, identify the gene and gene function:
9. Describe procedures for responding to an accidental spill and/or release:
10. Indic
ate any precautionary medical practices or advice and reasons why provided:
Recombinant DNA Research Form Page 2 of 3 Updated May 2016
Registration From
Recombinant DNA Research
11. Will this project involve the use of transgenic plant or animal species?
Yes
No
12. Provide a non-technical summary (include goals and objectives):
13. Attach a s
eparate technical summary, identifying the specific steps and protocols of the project.
I agree to fully comply with the NIH requirement pertaining to the shipment, transfer, and accident reporting for
recombinant DNA materials. I agree to abide by all provisions of the most current NIH Guidelines. I have carefully
reviewed and accept the responsibilities for Principal Investigators described in the NIH Guidelines. The information
above is accurate and complete.
PI signature: Date:
When completed, please return this document and all attachments to Environmental Health and Safety, 216 Browning Hall.
Recombinant DNA Research Form Page 3 of 3 Updated May 2016
For use by the Institutional Biosafety Committee (IBC) ONLY:
Approve with Stipulations* Disapprove
Conflict of Interest Approve
Signature IBC Chair: Date:
Stipulations:
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Registration Form Recombinant DNA Research (University of Memphis)

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Completed 5 February 2021

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