Download Recombinant DNA - Minneapolis Medical Research Foundation

Minneapolis Medical Research Foundation
Institutional Biosafety Committee
FOR COMMITTEE USE ONLY IBC# R _______________________
Application is:
Approved by Committee __________________________________
Approved with Modification ________________________________
Not Approved __________________________________________
ARTIFICIAL GENE TRANSFER AND
RECOMBINANT DNA FORM
Biosafety Chair __________________________________________
Date __________________________________________________
New submission

Grant renewal

Revised or resubmission
Date of previous submission

______
1.
Principal Investigator(s)
2.
Department
3.
Project Title
4.
Host - Vector System (e.g., E.coli K-12 & nonconjugative plasmids, Phage, Cosmids; Saccharomyces cerevisiae; etc.)
5.
Source of DNA (RNA) to be cloned
6.
Do you plan to modify an organism isolated from the environment in the last two years?
 Yes  No
7.
Do the DNA clones contain genes for the biosynthesis of toxic molecules lethal for vertebrates at an:
 a. LD50 of <100 nanograms/kilogram body weight
 b. LD50 of <100 micrograms/kilogram bodyweight
Lab. Location
Phone No.
 c. LD50 of >100 micrograms/kilogram body weight
 d. Genes for biosynthesis of toxic molecules not involved
8.
Do experiments use human or animal pathogens (Class 2, Class 3, or Class 4, Agents) as host-vector
systems?  Yes  No
9.
Do experiments involve the use of: a) infectious animal or plant viruses?
or b) defective animal or plant viruses in the presence of helper virus?
 Yes  No
 Yes  No
10.
Do experiments involve formation of recombinant DNA molecules containing >2/3 of the genome of any eukaryotic
virus?  Yes  No
11.
Do experiments involve the use of whole animals or plants?
12.
Do individual experiment involve more than 10 liters of cultures?
 Yes  No
 Yes  No
If yes, where (building & room #)
13.
What Biosafety Level (BL1, BL2, or BL3) will be used during this experiment?
14.
Do experiments involve the release into the environment of an organism containing recombinant DNA?
 Yes  No
If yes, has approval for this release been filed with state or federal regulating agency?
(agency)
(date filed)
Send copy of approval when it is received
Principal Investigator(s) Signature
Date
Please attach a description of your experiment and send to Carolyn Narikowa, MMRFS3.300 Labs, 612 873 6644
NOTE: If changes in information above occur, a revised form must be submitted.
Rev. 6/00