Download Biohazard Sorting Application Form This form must be filled out

Biohazard Sorting Application Form
This form must be filled out completely and sent electronically to Petra Pham, Operations
Director of the Flow Cytometry Shared Facility ([email protected]). Experiments
cannot be started until this application has been reviewed and approved. Additional information
may be requested before approval can be considered. Please allow at least one week for the
review and approval process to be completed.
Date:
Project Title:
Person making request:
Phone:
E-mail:
Laboratory Location:
Principal Investigator:
Description of Project. In one succinct paragraph, provide a description of the aim of the
experiments, and details of the cells or other material to be sorted. What is the species of
origin? Is there a known infectious agent involved? If a cell line is involved, what is its origin
and how long has it been in culture? Are there any known transforming agents involved (e.g.,
viruses such as EBV, SV-40 or vectors carrying known oncogenes)?
Are the samples going to be sorted or analyzed? Please circle.
Are the samples known to be infected with any of the following (indicate YES or NO):
HIV
HCV
HBV
Other, please specify
If a known infectious agent is involved, has it been inactivated (YES, NO, or N/A)?
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Biohazard Sorting Application Form
If yes, describe the inactivation method:
Were the cells transformed using a virus such as EBV, HTLV-1, herpes saimirii, etc. (YES
or NO)?:
If yes, list virus:
Were the cells genetically engineered (YES or NO)?
If yes, how were they engineered? Was a virus used (adenovirus, retrovirus, lentivirus,
herpes virus, etc.). List the virus and give a brief description of the system used:
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This section for use by Flow Cytometry Core Staff:
Date reviewed:
FACS Core Personnel involved in review:
Issues or concerns raised by review:
Conclusions of review (check one):
APPROVED
DENIED
CONTACT INVESTIGATOR FOR MORE INFORMATION
Signature of FACS Core Staff Member:
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