Download CDC select agent survey form

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CDC SELECT AGENT SURVEY
Principal Investigator/Name_____________________________
Date ___________________
Department ___________________________Room #____________Phone_________________
Title of Project: ________________________________________________________________
Please check one of the following:
____ I have reviewed the list of select agent microorganisms and toxins and I do not possess or
use any of these agents.
____ I do possess and/or use one or more of the select agents and have checked the agents I
possess below.
____ I do not currently possess or use any of the select agents but plan to do so in the future. I
have indicated those I plan to use below.
CDC Select Agents (Appendix A to 42 CFR Part 73)
Viruses
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1. Cercopithecine herpesvirus 1 (Herpes B Virus)
2. Crimean-Congo haemorrhagic fever virus
3. Eastern Equine Encephalitis virus
4. Ebola viruses
5. Equine Morbillivirus
6. Lassa fever virus
7. Marburg virus
8. Monkeypox Virus
9. Nipah and Hendra Complex viruses
10. Rift Valley fever virus
11. South American Haemorrhagic fever viruses (Junin, Machupo, Sabia, Flexal,
Guanarito)
12. Tick-borne encephalitis complex viruses
11. Variola major virus (Smallpox virus)
12. Venezuelan Equine Encephalitis virus
13. Viruses causing hantavirus pulmonary syndrome
14. Yellow fever virus
Bacteria
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1.
2.
3.
4.
5.
Bacillus anthracis
Brucella abortus, B. melitensis, B. suis
Burkholderia (Pseudomonas) mallei
Burkholderia (Pseudomonas) pseudomallei
Clostridium botulinum
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____ 6. Francisella tularensis
____ 7. Yersinia pestis
Rickettsiae
____ 1. Coxiella burnetii
____ 2. Rickettsia prowazekii
____ 3. Rickettsia rickettsii
Fungi
____ 1. Coccidioides immitis
____ 2. Coccidioides posadasii
Toxins
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1. Arbin
2. Aflatoxins
3. Botulinum toxins
4. Clostridium perfringens epsilon toxin
5. Conotoxins
6. Diacetoxysirpenol
7. Ricin
8. Saxitoxin
9. Shigatoxin
10. Staphylococcal enterotoxins
11. Tetrodotoxin
12. T-2 toxin
Attenuated Select Agents (Genetic Elements, Recombinant Nucleic Acids and Recombinant
Organisms)
____ 1. Select agent viral nucleic acids (synthetic or naturally derived, contiguous or
fragmented, in host chromosomes or in expression vectors) that have potential to encode
infectious and/or replication competent forms of any of the select agent viruses.
____ 2. Nucleic Acids (synthetic or naturally derived, and that are in a vector or host
chromosome; can be expressed in vivo or in vitro; or are in a vector or host chromosome
that can be expressed in vivo or in vitro) that have the potential to encode for the
functional form(s) of any of the toxins from the select agents listed above, OR their toxic
sub-units.
____ 3. Any of the viruses, bacteria, fungi, and toxins listed above that have been genetically
modified.
PI Signature: _______________________________________________________________
**** Mail completed survey to EHS at Fuller Building 470 or fax to 638-8822 ****
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