Download Biosafety Questionnaire for Shared Flow Cytometry Facilities

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):
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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.
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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)
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Last updated: 8/4/06