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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