University of Alabama

Application for Recombinant DNA  - Biological Safety Program

Investigator  ________________________________________________________________

Building(s)  ________________________________         Room(s)  ____________________ 

Dept  ____________________________________           Date  _______________________

All research conducted at the University of Alabama involving R-DNA must meet current NIH guidelines. See Federal Register of April 2002 (or most recent) at http://www.niehs.nih.gov/odhsb/ .

Under all circumstances, whether or not your cloning research is exempt, you must fill out the Application for Recombinant DNA.

These guidelines group protocols into six classes based on their perceived risk.  Five of these classes require review by a local committee.  High-risk experiments require review by national committees. The Institutional Biological Safety Committee (IBSC) is the local committee that reviews experiments identified by the R-DNA Registration Document. You, as the PI, are responsible for determining the status of your experiments and completing and submitting this R-DNA Registration Document.

Many experiments considered safe are exempt from filing and review, i.e., cloning a non-toxic gene from a non-pathogenic organism in a suitable phage or plasmid propagated in E.coli K-12 employing standard microbiological techniques. Such experiments are defined as “exempt” in Section III-F and Appendices A & C of the Guidelines. If the experiments are in this class (III-F), we ask that the researcher/teacher submit a R-DNA Registration Form to obtain IBSC documentation of exempt status, since some granting agencies now require this documentation. Please be aware, however, that there are factors – large-scale culture, releasing organisms containing recombinant DNA from the lab – which shift an exempt procedure to the non-exempt class.

 

Office Room #

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Office Phone #

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Lab Phone #

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E-mail Address:

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Building and Room(s) where project will take place:

____________________________________________________

Project Title:

_________________________________________________________________________________________

 

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Project Period:

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to

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Granting Agency:

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Briefly describe the goal of  your experiment in non-scientific terms (Layman’s Terms):                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         

           

 

Please list the names, telephone numbers, and e-mail addresses of those who may come into contact with the agents listed in this registration document:

Name:

Office Telephone #

Emergency Telephone #

E-mail Address:

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Where is this project carried out?        ______________________________________________________

 

Which of the six NIH categories apply to the proposed project?

III-A

Require IBSC approval, RAC review and NIH Director approval before initiation.

 

III-B

Require NIH/OBA and IBSC approval before initiation.

 

III-C

Require IBSC and Institutional Review Board approval and RAC review before research participant enrollment.

 

III-D

Require IBSC approval before initiation.

 

III-E

Require IBSC approval simultaneous with initiation.

 

 

III-F

Exempt experiments. (Although no registration is required for exempt experiments, please complete this entire form for IBSC review.)

 

 

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

NIH: National Institutes of Health       OBA:  Office of Biotechnology Activities   

RAC: Recombinant DNA Advisory Comm.

 

 

Which level of containment applies to the proposed project?

Biosafety Level 

1

2

3

4

______

I am not sure of the appropriate biosafety level for my research.

Animal Biosafety Level

1

2

3

4

Plant Biosafety Level

1

2

3

4

 

 

 

 

Recombinant DNA experiment and/or project details   (use additional sheets if necessary)

Host/Environment

 

 

Esherichia coli K-12

Yes  [ ]     No [ ]

BSL-1 [ ]    BSL-2 [ ]  

Other Bacteria

Yes  [ ]     No  [ ]

 

        Nonpathogen

Yes  [ ]     No  [ ]

 

        Pathogen Risk Group 2 (BSL-2)

Yes  [ ]     No  [ ]

 

        Pathogen Risk Group 3 (BSL-3)

Yes  [ ]     No  [ ]

 

Toxin Gene

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]   BSL-3 [ ]

Drug Resistance Gene  

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]   BSL-3 [ ]

Yeast/YAC

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]  

Tissue Culture Cells

Yes  [ ]     No  [ ]

 

        R-DNA/Plasmids

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]  

        Segment of Virus

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]  

        Virus Vector

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]   BSL-3 [ ]

         If Virus Vector:

AAV [ ]   Adeno [ ]  Retro [ ]   Vaccinia [ ]   Other [ ]

Characterized/FDA or NIH approved/Novel

 

 

Intact Laboratory Animal Recipient

Yes  [ ]     No  [ ]

Species:

        R-DNA/Plasmids   

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]  

        Transgenic

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2[ ]  

        Virus Vector

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]   BSL-3 [ ]

        SCID/Nude

Yes  [ ]     No  [ ]

BSL-1 [ ]    BSL-2 [ ]   BSL-3 [ ]

Has Institutional Animal Care and Use Committee been notified?

Yes  [ ]     No  [ ]

 

Human Subject Recipient          

Yes  [ ]     No  [ ]

Has IRB Been Notified? Yes [ ]No [ ]

IRB Approval Number:

        R-DNA/Plasmids

Yes  [ ]     No  [ ]

BSL-2 [ ]   BSL-3 [ ]

        Pathogen

Yes  [ ]     No  [ ]

BSL-2 [ ]   BSL-3 [ ]

        Virus Vector

Yes  [ ]     No  [ ]

BSL-2 [ ]   BSL-3 [ ]

Plants/Insects  

Yes  [ ]     No  [ ]

 

Field Release   

Yes  [ ]     No  [ ]

BSL-2 [ ]   BSL-3 [ ]

Is a deliberate attempt made to obtain expression of foreign gene(s) in the cloning vehicle?

Yes  [ ]     No  [ ]

If yes, what proteins, materials, or antigens?

 

 

Will this project require large-scale fermentation (>10 liters) of organisms containing recombinant DNA molecules?

 

Yes

No

 

 

 

 

Will this project, at some point, require the release of organisms containing recombinant molecules into the environment?

Yes

No

      If Yes, attach a copy of any USDA permits or applications.

 

 

 

Will this project involve the use of transgenic plant or animal species?

Yes

No

 

If yes, please identify species:

                                                                                                         

               

 

 

 

 

Will there be any attempt to transfer recombinant DNA molecules in vivo to plant or animal systems (other than tissue culture)?

 

Yes

No

 

 

 

 

Will there be a petition to NIH for exemption from the guidelines?

Yes

 

No

 

 

 

 

 

 

Describe procedures for responding to an accidental spill and/or release

 

 

 

 

 

 

Indicate any precautionary medical practices.  Explain the requirement.

 

 

 

 

 

 

 

 

Attach a short, clear summary of your proposed recombinant experiments that will explain their essential features. Avoid jargon and excess technical detail. Include the following and any other data that you feel has important bearing upon the decision-making process.  Explain the significance of the experiments and exactly why you are performing operations that make the experiments non-exempt. If appropriate, explain and justify the use of pathogenic organisms not named in Appendix B of the NIH Guidelines, or of the Biological Containment Host-Vector System if it is important for the safety of the experiment and not named in Appendix E. Describe any special precautions required for containment and personal safety.

 

 

Additional Comments/Information

 

 

I hereby apply for approval of my plans for experiments involving recombinant DNA molecules.  I am familiar with, and agree to abide by, the provisions of the current NIH Guidelines (April 2002 Federal Register (or later) and appendices), and any other specific NIH or University of Utah instructions pertaining to the proposed project. I agree to provide the IBC prompt written notification of any significant changes in these protocols or of any major accidents involving recombinant DNA molecules. I agree to comply with NIH requirements pertaining to shipment and transfer of recombinant DNA materials. I certify that all herein provided information is accurate and complete.

 

I accept responsibility for the safe conduct of work with this material as indicated on any page of this form. I will ensure that all personnel receive appropriate training in regard to proper safety practices and personal protective equipment needed for this work and that all building occupants are educated when warranted. I certify that all herein provided information is accurate and complete.

 

Print Name:

Date:

Signature:

 

 

******** This box is for Institutional Biosafety Committee (IBC) use only **********

Approve

Approve with Stipulations    

Disapprove

Conflict of  Interest

Registration #:                                     

Approval #:                                           

Containment Level:                                  

Stipulations:

                                                                                                                                                                                                   

 

                                                                                                                                                                                                   

Signature IBC Member:

                                                                        

Date