Download UNIVERSITY OF OKLAHOMA

The University of Oklahoma – Norman Campus
Institutional Biosafety Committee
Protocol Form
Please use this form for new submissions only. Resubmissions of a previously approved protocol to the same or alternate
funding source or for minor modifications(such as location), please use the Protocol Resubmission Form.
1.
Principal Investigator(s) (PI) Name and Degree: Click here to enter text
Department: Click here to enter text
Title: Click here to enter text
Campus Address: Click here to enter text
2.
Phone: Click here to enter text
Fax: Click here to enter text
Co-Principal Investigator (Co-PI) Name and Degree: Click here to enter text
Department: Click here to enter text
Title: Click here to enter text
Campus Address: Click here to enter text
Phone: Click here to enter text
3.
Project Title: Click here to enter text
4.
Funding Agency: Click here to enter text
5.
Dates of Project: From: Click here to enter text
6.
Project Location (Building and Room #): Click here to enter text
Fax: Click here to enter text
To: Click here to enter text
For Recombinant DNA Protocol:
7.
What is the source of recombinant or synthetic DNA to be used in the project (e.g., species)? Click here to enter text
8.
Describe the nature of the inserted DNA sequences (e.g., structural gene, oncogene) Click here to enter text
9.
Identify the recipient host(s): Click here to enter text
If a microorganism, identify specific strain: Click here to enter text
If a cell line, identify the specific cell line: Click here to enter text
10. What vector(s), if any, will be used: Click here to enter text
11. Will the resulting recombinant DNA molecule contain the genome from any eukaryotic virus?
If yes, indicate the percentage of viral genome
<1/2
12. Will an attempt be made to obtain expression of a foreign gene?
>1/2 but <2/3
Yes
Yes
No
>2/3
No
If yes, indicate the protein that will be produced: Click here to enter text
13. Does the proposed mutation involve a deliberate transfer of a drug resistance trait to a microorganism, and does such acquisition
compromise the use of the drug to control disease agents in humans, veterinary medicine, or agriculture?
Yes
For Microorganism Usage:
14. What microorganism(s) will be used (identify specific strains): Click here to enter text
15. Describe the agent’s characteristics (e.g., virulence, pathogenicity, environmental stability): Click here to enter text
For All Protocols:
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No
16. Describe how you will use recombinant DNA and/or microorganisms in the protocol: Click here to enter text
17. Describe the containment conditions that will be used, such as use of a biological safety cabinet and personal protective equipment:
Click here to enter text
18. Proposed biosafety level
19.
BSL1
BSL2
Provide copies of the safety information that will be posted in your laboratory and signage, spill cleanup procedures, access
limitations, etc. (attach additional pages as needed): Click here to enter text
20. Have all personnel involved with this experiment received documented initial training and yearly updates regarding the handling of the
hazards and proper safety and reporting procedures for this protocol?
Yes
No
21. Attach a copy of the proposed specific aims and project summary/abstract. Please also provide any other information you
feel that would be helpful to the IBC where you describe the protocols you are proposing to use for this project so that the IBC can
have a good idea of the experiments you are proposing.
Principal Investigator (electronic) signature:
___________________________________________________Date__________________
Please complete this form and e-mail it to Andrea Miller ([email protected])
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