Medical Treatment Indicate the personnel protective equipment you will use. Please check the applicable boxes. Lab coats Boots/Crocs Head covers Shoe Covers Disposable outers Gloves Double gloves PAPR (HEPA)* N 95 (HEPA)* P100 (HEPA)* Eye protection Face shield Face Mask Other (Specify :) *Please contact the TAMUK Occupational Health Program at (361) 593-4510 or by email at to obtain required Fit Testing, Pulmonary Function Testing, and/or Respiratory Training. Biological Safety Cabinet Indicate the type of Biological Safety Cabinet(s) (BSC) you intend to use. Please check the applicable boxes and enter the location IDs: Class Location ID Certified Most Recent Annually? Certification Date 1 Class II A (recirculating) Yes / No 2 Class II B1 (70% exhausted ducted outside) Yes / No – 3 Class II B2 (100% exhausted ducted outside) Yes / No – 4 None Yes / No 5 Other (Specify): Yes / No PART II - Agent Information Table A: Agent/Vector/Host characteristics In the table below, list each agent that will be used. Note the ID of the agent for later use in your application. If the agent is recombinant, pick in the appropriate cell and enter insert information into Table B. Please note “Yes” that if a vector is used to generate a recombinant host, both the vector and host need to be entered into Table A. If the agent is to be used with animals or plants give the species, otherwise enter “No”. List all location IDs Use in where agent will be ID Genus, species Strain RG BSL ABSL Recombinant? Animals/Plants? used / stored (give species) (from Part I, Section F) - Example K-12 RG-1 BSL-1 N/A Yes 1,2,3 No E. coli – A-1 A-2 A-3 A-4 A-5 A-6
Medical Treatment Indicate the personnel protective equipment you will use. Please check the applicable boxes. Lab coats Boots/Crocs Head covers Shoe Covers Disposable outers Gloves Double gloves PAPR (HEPA)* N 95 (HEPA)* P100 (HEPA)* Eye protection Face shield Face Mask Other (Specify :) *Please contact the TAMUK Occupational Health Program at (361) 593-4510 or by email at to obtain required Fit Testing, Pulmonary Function Testing, and/or Respiratory Training. Biological Safety Cabinet Indicate the type of Biological Safety Cabinet(s) (BSC) you intend to use. Please check the applicable boxes and enter the location IDs: Class Location ID Certified Annually? Most Recent Certification Date 1 Class II A (recirculating) Yes / No 2 Class II B1 (70% exhausted – ducted outside) Yes / No 3 Class II B2 (100% exhausted – ducted outside) Yes / No 4 None Yes / No 5 Other (Specify): Yes / No PART II - Agent Information Table A: Agent/Vector/Host characteristics In the table below, list each agent that will be used. Note the ID of the agent for later use in your application. If the agent is recombinant, pick “Yes” in the appropriate cell and enter insert information into Table B. Please note that if a vector is used to generate a recombinant host, both the vector and host need to be entered into Table A. If the agent is to be used with animals or plants give the species, otherwise enter “No”. ID Genus, species Strain RG BSL ABSL Recombinant? List all location IDs where agent will be used / stored (from Part I, Section F) Use in Animals/Plants? (give species) - Example – E. coli K-12 RG-1 BSL-1 N/A Yes 1,2,3 No A-1 A-2 A-3 A-4 A-5 A-6
02-21-17_IBC%20Forms%20Combined.docx