If the organization has other facilities off-site, please complete the following table: No. of facility off-sites: No. of staff Site location Type of work performed Shift time/staff no. during shift (FT/PT/SE) INVOICING INFORMATION Contact person: Contact no.: Email: Address (if different from above): The need/rationale for retaining poliovirus materials post-eradication: Cease work and storage Expected date of completion: Actions taken for retained poliovirus samples before CP expiry or ICC/CC issuance: Expected date Means of Destroyed of destruction: destruction: Transferred to containment Transfer to: Transfer date: within an alternative PEF: Manipulated or stored as part of an ongoing programme of work Actions taken for retained poliovirus samples before CP expiry or ICC/CC issuance: Expected date Submission of Applied for of ICC/CC time-bound YES NO ICC/CC achievement: action plan: Storage Held in secure storage Location: conditions: Used for Specify other activities: activities
If the organization has other facilities off-site, please complete the following table: No. of facility off-sites: Site location Type of work performed No. of staff (FT/PT/SE) Shift time/staff no. during shift INVOICING INFORMATION Contact person: Contact no.: Email: Address (if different from above): The need/rationale for retaining poliovirus materials post-eradication: Cease work and storage Expected date of completion: Actions taken for retained poliovirus samples before CP expiry or ICC/CC issuance: Destroyed Expected date of destruction: Means of destruction: Transferred to containment within an alternative PEF: Transfer to: Transfer date: Manipulated or stored as part of an ongoing programme of work Actions taken for retained poliovirus samples before CP expiry or ICC/CC issuance: Applied for ICC/CC Expected date of ICC/CC achievement: Submission of time-bound action plan: YES NO Held in secure storage Location: Storage conditions: Used for other activities Specify activities:
CCS_-ApplicationForm-19022017-EN.docx