Download Biohazard Permit Form

Biohazard Permit Form
POST THIS PERMIT IN YOUR AREA
For Office Use Only
Permit #:
Expiry Date: Click here to
enter a date.
To meet the requirements of the Brock University Biosafety Program, a Biohazard Permit Form must be approved by the
Biosafety Committee or Biosafety Officer prior to purchasing, importing, exporting, transferring or conducting work involving
controlled human, animal, or plant biohazards. Intended changes to an existing project, e.g. personnel, type of biohazardous
agent or its location, decommissioning or changes affecting the required level of containment must be approved by the
Biosafety Committee as well prior to its implementation. Agents requiring a Biohazard Permit are listed in section section F.
Work involving a controlled toxin, aquatic animal pathogen, and/or plant pest, may require additional forms referred at the
end of this doc. Send completed form(s) to Leila Vistorte via email [email protected], interoffice mail, or drop it at Cairn 507 .
PLEASE TYPE
A- Principal Investigator (PI)
Name
Email
Phone-office ext.
Phone-Lab ext.
@brocku.ca
Phone emergency
[To add another contact select both rows, right click over the selection and Copy it. Bring the cursor to just below the lower row (at the beginning) and right click on the spot,
then select Paste (Keep source formatting)]
B- Main Laboratory Contact(s)
Name
Email
Phone-office ext.
Phone-Lab ext.
@brocku.ca
Phone emergency
[To add another contact select both rows, right click over the selection and Copy it. Bring the cursor to just below the lower row (at the beginning) and right click on the spot,
then select Paste (Keep source formatting)]
C- Permit Type.
☐ New
☐ Renewal
☐ Amendment
D- Proposed Containment Level
☐ CL2
☐ AQC-1
☐ PPC-1
☐ CL2Ag
☐ CL3
E- Project Title and Funding Sponsor/ Granting Agency
Project Title
Sponsor/ Agency
Grant #
Dates Held
F- Biohazardous Agents. Please check all that apply.
☐ Human tissue /Cells
☐ Human blood /blood fractions
☐ Human body fluids
☐ Primary human cell lines
☐ Established human cell lines (rated either CL2, BSL2, or RG2) ☐ Animal body fluids
☐ Animal tissue/cells
☐ Established animal cell lines (rated either CL2, BSL2, or RG2)
☐ Animal blood/blood fractions
☐ Non-microbial
☐ Primary animal cell lines
toxins
☐ Bacteria
☐ Virus
☐ Fungi
☐Viral Vector
☐ Parasite ☐ Microbial Toxins
☐ Prion
☐ Genetically modified microorganism
☐ Genetically modified plant ☐ Security Sensitive Biological Agents (Check Here)
(GMM)
(GMP) The personal information requested on this form is collected under the authority of The Brock
[Brock University protects your privacy and your personal information.
University Act, 1964, and in accordance with the Freedom of Information and Protection of Privacy Act. For details on the use and disclosure of this information call the
Biosafety Officer at (905) 688-5550, ext. 6179.]
BHP Form v3.0 Brock University. http://brocku.ca/hr-ehs/environment-health-safety/academic-safety/biosafety
Page 1 of 4
Biohazard Permit Form
G- Identify the biohazardous material that is being used and that is being stored.
Common Name (include species, e.g. human lung
Scientific Name (e.g. A549)
carcinoma cell line)
Use
Stored Only
☐
☐
☐
☐
☐
☐
☐
☐
[To add another material select last row, right click over the selection and select Insert – Insert Rows Below]
G1- Do you keep an updated inventory of the biohazardous material by location and containment level designation? ☐Yes ☐No
H- Project Location (include also rooms used for storage only, shared equipment rooms, etc.)
Building
Room # Room Use (e.g., Cold Room, Tissue Culture)
Cont. Level
[To add an additional row click Tab while the cursor is on the last cell]
I- List all Biosafety Cabinets (BSCs) to be used and provide the following info.
IMake on them.
Class
Type
Building
Room #
Year Last Certified
[To add an additional row click Tab while the cursor is on the last cell]
J- Training
List all laboratory users (employee and student). All must have attended the Biosafety training provided by Health, Safety &
Wellness (HSW) and additionally, the job-specific training provided by the PI.
Date of
Date HSW
Date HazardName
Title/Position
Appointment
Training
Specific Training
Click here to
Click here to enter
Click here to
enter a date.
a date.
enter a date.
Click here to
Click here to
Click here to enter
enter a date.
enter a date.
a date.
Click here to
Click here to
Click here to enter
enter a date.
enter a date.
a date.
Click here to
Click here to
Click here to enter
[To add an additional row click Tab while the cursor is on the last cell]
enter a date.
enter a date.
a date.
K- Radiation Usage with Biohazards.
☐ None
☐ Radioisotope ☐ Irradiator ☐ X-ray ☐ Laser ☐Other- specify:
☐ Approved: #
☐ Approval Pending
L- Animal Usage with Biohazards. Refers to animals of unknown health status (e.g., wild), known or suspected to carry a
pathogen, or those that are known to harbor pathogens.
☐None
☐Approved: #
☐ Non-human primate ☐ Non-primate animal- specify:
☐ Other- specify:
☐Approval pending
BHP Form v3.0 Brock University. http://brocku.ca/hr-ehs/environment-health-safety/academic-safety/biosafety
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Biohazard Permit Form
M- Procedures and Operations
Check the procedures and operations performed with biohazardous material in chart below; also indicate practices employed to
mitigate the risks posed by submitting a copy of the lab operating procedure. e.g. of mitigation strategies: use of sealed safety
cups when centrifuging stocks of microorganisms; use of sharps container for the disposal of sharps waste and placement of
such containers near the source of generation.
Yes No
Yes No
Blending
☐ ☐
Pouring infectious materials
☐ ☐
Centrifuging
☐ ☐
Culturing pure pathogens
☐ ☐
Cell Sorting
☐ ☐
Flaming inoculating loops
☐ ☐
Vortexing
☐ ☐
Work with animals (potential bites/scratches)
☐ ☐
Grinding
☐ ☐
Transport biohazardous material outside of the lab
☐ ☐
Homogenizing
☐ ☐
Work with large volume of biohazardous material (>1L)
☐ ☐
Sonication
☐ ☐
Collection of samples - specify type:
☐ ☐
Toxin production
☐ ☐
Culturing samples - specify type:
☐ ☐
Use of sharps
☐ ☐
Surgery/vivisection- specify species:
☐ ☐
Vigorous shaking
☐ ☐
Other- specify:
☐ ☐
Cryogenic techniques
☐ ☐
N- Decontamination Method/ Waste treatment.
Select and/or describe the decontamination method(s) employed. For guidance on decontamination methods and waste treatment
procedures at Brock refer to the Biosafety Manual 2015 - Chapter 10 available at this link.
☐NA
Liquid Waste: ☐Chemical ☐Autoclaving  When autoclaving is selected, where is the autoclave located?
 When autoclaving is used, is the autoclave monitored weekly with BI(S)? ☐Yes ☐No
Lab Clothing: ☐Chemical ☐Autoclaving
 Are records of weekly monitoring with BI produced, kept and stored for a minimum of two
Solid Waste:
years?
☐ Yes
☐No
Animal carcass:
Sharps:
N1- How often is waste decontaminated and/or disposed of?
Liquid W: ☐ At the end of workday ☐ Other: specify
Solid W:
☐ At the end of workday ☐ Other: specify
Sharps: ☐ When container is ¾ full
☐ Other: specify:
Lab Clothing: ☐ Upon a confirmed or suspected contamination with infectious material
☐Other-specify:
☐ When visibly soiled
O- Medical Surveillance
Yes No NA
☐ ☐ ☐
☐ ☐ ☐
Is immunoprophylaxis and/or vaccine available?
Has every user of the biohazardous material been informed of associated risks, potential source(s) of exposure
and risk-mitigation strategies?
Has every user of the biohazardous material been informed of signs and symptoms associated with disease
☐ ☐ ☐
acquisition?
Are incidents of exposure or potential exposure communicated in a timely manner to the PI and records of
☐ ☐ ☐
this produced and kept in the lab?
Have lab personnel been informed that medical clearance is necessary in order for them to work with infectious ☐ ☐ ☐
materials if they are immunocompromised or pregnant?
BHP Form v3.0 Brock University. http://brocku.ca/hr-ehs/environment-health-safety/academic-safety/biosafety
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Biohazard Permit Form
Is there a potential of the plant to become a weed?
☐ NA
Yes No
☐ ☐
Is there a potential of a plant to create a weed by cross-pollinating with another plant?
☐ ☐
P- For GM Plants only. When applicable indicate if the following has been assessed, otherwise select NA.
Is there a potential impact on biodiversity?
☐ ☐
O-1 If any of the above answers is Yes, indicate practices employed to mitigate the risks posed by submitting a copy of the
lab operating procedure.
Q- Required Names and Signatures
As the Principal Investigator of this project, I hereby declare that the information provided in this BHP form is
complete, true, and accurate to the best of my knowledge and belief. I will ensure that any research and/or teaching
under my direction conform to the standards set out by the University (in the Biosafety Manual), Provincial and
Federal policies and regulations that govern activities involving biohazardous materials and agents. I have been
made aware that in order to receive, purchase, import, export and/or transfer any biohazardous material listed in
section F, I must contact the Biosafety Officer in anticipation.
Principal Investigator
Biosafety Officer
Biosafety Committee Chair
Signature
Click here to enter a date.
Date
Signature
Click here to enter a date.
Date
Signature
Click here to enter a date.
Date
Additional Containment Level-Associated Forms
All forms and some supplemental information are available in the Biosafety section within the HSW webpage, at this link
http://brocku.ca/hr-ehs/environment-health-safety/academic-safety/biosafety
Plant Pests
In addition to the Biohazard Permit Form (BHP) form, those who plan to work with plant pests must fill out the Plant Pest
Containment Level 1 Self-Assessment Checklist and review the Containment Standards for Facilities Handling Plant Pests available
at this link: http://www.inspection.gc.ca/plants/plant-pests-invasive-species/biocontainment/containmentstandards/eng/1412353866032/1412354048442. Then, contact the BSO who will assist in submitting the permit application to the
Canadian Food Inspection Agency (CFIA).
Toxins
In addition to the BHP form, those who plan to work toxins whether of microbial or non-microbial origin must fill out the
Biohazard Permit Form - Toxin Attachment.
Aquatic Animal Pathogens
In addition to the BHP form, those who plan to work with aquatic animal pathogens must review the Containment Standards for
Facilities Handling Aquatic Animal Pathogens available at this link:
http://www.inspection.gc.ca/animals/aquatic-animals/imports/pathogens/facilities/eng/1377962925061/1377963021283. Then
contact the BSO to assist in submitting a permit application to the CFIA.
Risk Group 1 Human and Terrestrial Animal Pathogen
Those whose work does not fall into any of the categories above and will work with material that is not pathogenic or that has low
likelihood of causing disease must fill out the Containment Level 1 Clearance Form, in order to ensure that a proper risk
assessment has been completed.
BHP Form v3.0 Brock University. http://brocku.ca/hr-ehs/environment-health-safety/academic-safety/biosafety
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