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Thomas E. Starzl Transplantation Institute Flow Cytometry Core Facility E1514 BST | (412) 624-0286 | Fax (412) 624-6666 Biosafety Questionnaire for Shared Flow Cytometry Facilities (Recommended by ISAC Biosafety committee and referenced from Schmid I, Merlin S, Perfetto SP. Biosafety concerns for shared flow Cytometry core facility. Cytometry. 2003 56A:113-119) Flow Cytometry Core Laboratories are multi-user facilities where many different samples from various sources, which may contain known or unknown human pathogens, are investigated. The safety of the staff and users of the facility is of ultimate concern. Information about the sample sources and potentially infectious agents is critical for effective biosafety measures. Consequently, this sample information form must be completed and signed by the principal investigator of the laboratory who is requesting samples to be analyzed or sorted in the STI flow cytometry core facility before the experiments or projects are initiated. The completed biosafety questionnaire will be kept on and should be updated when any of the information changes. Appropriate biosafety approval of experiments prior to sample submission to the flow cytometry core facility is required. Date: Principal Investigator (Laboratory Director): Phone number: Fax number: E-mail: Investigator: Phone Number: Fax Number: E-mail: Laboratory Location (Building and Room): 1 Last updated: 8/4/06 Project title (if any): Summary or Description of Project. Provide one paragraph of details related to cells that will be analyzed or sorted. List type of sample and source (i.e., mouse spleen cells, human peripheral blood mononuclear cells, cells from an animal en-grafted with human cells, etc.); for cell lines, describe cell origin. Does the sample contain any known infectious agent(s)? Yes No List agent(s) -- Provide Biosafety Level of agents using the classifications system listed in the “Biosafety in Microbiological and Biomedical Laboratories”, US Department of Health and Human Services, 4th edition. Has the infectious agent been inactivated? Yes No If yes, describe method of inactivation. Provide proof of inactivation, if applicable. Were blood cell donors screened for blood borne pathogens, e.g., HIV, HBV, HCV? Yes No If yes, list test results, positive or negative. 2 Last updated: 8/4/06 Could the sample contain other known human pathogens? If yes, list agent(s). Yes No Were the cells transformed using a virus such as EBV, HTLV-1, herpes saimirii? Yes No If yes, list virus. Were the cells genetically engineered? How were they genetically engineered? Was a gene therapy virus (adenovirus, retrovirus, lentivirus, herpesvirus, etc.) used to transfer genetic information into the cells? Yes No If yes, describe method in detail, attach vector map and show packaging cell line. Have the cells been tested for mycoplasma infection and/or viral infection (HIV, HBV, SIV, etc.)? Yes No If yes, give date of last test(s) and test(s) results Tests must have been performed just prior to sample submission to the flow cytometry core facility. Will the samples be fixed prior to submission to the core flow cytometry core facility? Describe the fixation protocol in detail, e.g., list concentration and exposure time. I have read the above questions carefully and certify that the information provided is correct. _____________________________ Signature (Principal Investigator) 3 Last updated: 8/4/06