A / Where will Human Tissue samples/specimens be collected? (check all that apply)
1. VA Facility, Research Area(s) (Bldg: , Room: )
Collected by: Clinical Staff
Research Staff (Specify: )
2. VA Facility, Clinical Area(s) (Bldg: , Room: )
Collected by: Clinical Staff
Research Staff (Specify: )
3. Affiliate Check one UC Davis UC Berkeley
(Bldg: , Room: )
4. Other (specify: )
5. NOT APPLICABLE (Explain: )
B / Personnel handling human tissues/specimens? (check all that apply)
1. VA Research Staff (includes WOC appointments)
2. VA Clinical Staff
If box 1 is checked above, please complete items C- G below
C / Will VA research personnel (includes WOC) work with blood or body fluids? Yes No
If “yes”, specify what material personnel will work with:
D /
Will VA research personnel (includes WOC) work with organs or tissues? Yes No
If “yes”, specify which tissues or organs personnel will work with:E / Will VA research personnel (includes WOC) work with human-derived cells or cell lines? Yes No
If “yes”, specify name of cell or cell line:
F / Are VA research personnel (includes WOC) informed of post exposure prophylaxis in case of accidental exposure to human tissues/fluids?
Yes No Not Applicable
G / All VA research personnel will follow universal precautions for safe handling of blood, cell, tissue, and bodily fluids, including the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear. In addition, all employees are advised to take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices. All personnel working with human tissues are provided detailed instructions regarding risks and proper handling of potential biohazards.
For all VA RESEARCH personnel involved in this study who will be handling blood, cell, tissue and bodily fluid, provide names and date of any relevant training in addition to the CITI - VA Human Subjects Protection and Good Clinical Practices (GCP) (e.g. Phlebotomy training if you are going to draw blood). If you have ONLY completed GCP training, please leave blank.
NAME OF PERSONNEL / NAME OF TRAINING (i.e., CITI Biosafety, UC Davis Lab Safety Trg, etc.) / DATE OF COMPLETION
V: 01/25/2016 VA Form 10-0398 Appendix 2 Page 1 of 1