Fillable Request to Continue Essential Research in on-campus research (Lakehead University)

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Request to Continue Essential Research in on-campus research (Lakehead University)

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The Request to Continue Essential Research in on-campus research (Lakehead University) form is 3 pages long and contains:

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  • 37 check-boxes
  • 23 other fields

Country of origin: CANADA
File type: PDF

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Exemption Request Form. Please send to vpresearch@lakeheadu.ca Page 1 of 3
Request to Continue Essential Research in on-campus research laboratories and facilities Form
Lakehead University Thunder Bay and Orillia Campuses
Please send this form to the Vice-President, Research and Innovation only after it has been signed-off by your
Faculty Dean.
A fully signed copy of this form should be kept and posted in your laboratory.
To be granted an exemption to the University’s decision to restrict all on-campus research activity
on the Thunder Bay and Orillia campuses, justification for the exemption, requires
the approval of your Faculty Dean and Vice-President Research and Innovation. Please
send this form once signed by the Faculty Dean to vpresearch@lakeheadu.ca. We will
respond to the email address provided for the Principal Investigator below, cc: to the Dean and
Director, Research Services.
The following criteria will be considered in the decision to grant the exemption:
• The nature of the project:
o Does it involve COVID-19 research?
o Does it involve maintaining critical research material that cannot otherwise be preserved
(e.g., biological materials, living plant collections, etc.)?
o Is this research that is at a critical stage or close to an end-point?
• Is the exemption being requested to allow you to take simple steps to sustain a collection, such
as topping up liquid nitrogen stocks or moving samples into a more sustainable storage container?
• Will the number of people required to do the work be able to respect social distancing protocols?
Campus:
Thunder Bay Orillia
Name of Principal
Investigator:
Department/Faculty:
Building/Room #'s:
Email:
Primary Mobile
Phone Number:
Title of Project:
Personnel who will
access the
research facility:
(list Principal
Investigator first)
Graduate student Post-doctoral Fellow Staff
Personnel #1:
Mobile Phone Number:
Faculty member
Personnel #2:
Mobile Phone Number:
Faculty member
Graduate student Post-doctoral Fellow Staff
NOTE: If only one person will be accessing the facility, please include the plan for
ensuring that person’s safety and security in the safety plan section of this form.
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All personnel who will be working on site under this exemption have completed
All required H&S related traini
ng.
Exemption Request Form. Please send to vpresearch@lakeheadu.ca Page 2 of 3
Requires access to:
Laboratory
Animal Facilities
CL-2
Approved ACC Protocol Number:
LUACF
Biology Aquatics Facility
Aquatics Toxicology Research Ctr.
Office Other (please specify):
Compliance
Certificates on File:
Biosafety Radiation Safety
None
Human Animal
Other (please describe in
detail):
Do you require any
of the following
supplies to conduct
this research?
Personal Protective Equipment
Gases
Liquid nitrogen
Will this research generate any waste that will require special handling to dispose of safely?
Yes No
If YES, please elaborate:
How long do you require this exemption for? _____ weeks ________ continually required
The requested exemption relates to:
Research directly related to COVID-19
Maintaining critical research material*
Topping up research storage (e.g. with liquid nitrogen)
Other
Provide rationale:
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*A critical research material is one that could not be replaced through other means.
Lakehead University Centralized Facilities
Lakehead University Analytical
Facilities
Plant Care Facilities
Main Campus Greenhouse
Other
Related ROMEO Number:
(note that new Biosafety Certificate of Approval will be required)
Please use Adobe Reader to complete this form
DECISION: Approved Declined
Notes:
Faculty Dean
Vice-President Research &
Innovation
Signature: Signature:
Or click box to add scanned signature:
Or click box to add scanned signature:
Name:
Name:
Exemption Request Form. Please send to vpresearch@lakeheadu.ca Page 3 of 3
Approvals:
Please provide the names of any approved, qualified personnel who may substitute for the named personnel
on this form:
Please outline a safety plan for this project, including a safety plan if people are working alone below:
PLEASE ENSURE APPROVALS AND SIGNATURES ARE OBTAINED FROM
DEAN BEFORE SUBMITTING TO vpresearch@lakeheadu.ca
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Request to Continue Essential Research in on-campus research (Lakehead University)

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Completed 2 December 2020

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