ANIMAL HAZARDOUS AGENTS FORM

PROTOCOL ATTACHMENT

Instructions: This attachment must be submitted with every protocol application. Amendments involving new/additional hazards must be submitted with an updated version of THIS approved form. The information is for review and approval by Office of Environmental Health & Safety (OEHS). Hazardous agents listed in Section I, II or III that are used in-vivo may require additional written safety procedures. View the following link for more information: Animal Hazardous Agents Forms. For more information contact OEHS at 577-1200.

PRINCIPAL INVESTIGATOR: / DATE:
PROTOCOL NUMBER: / Amendment Revision Date:

I.BIOLOGICAL HAZARDS:

Does this researchinvolve the use of any recombinant DNA, mammalian viruses, biological toxins, infectious agents, human blood, human cell lines, human tissue, and/or transgenic animals?

NO
YES – List below:

The use of certain biological agents requires review and approval by the WSU Biosafety Committee. To determine if this applies to your research, follow the instructions and complete the applicable Biological Agent User Application Forms.

a.Biological Hazard Type(mark and list all applicable hazards):

X, if yes / Type / List
HHS and USDA Select Agents and Toxins1:
Human Cell Lines2, Tumors, Blood, etc.:
Infectious Agents:
Non-plasmid recombinant DNA:
Plasmid recombinant (NIH Exempt) DNA:
Transgenic/Knockout/Knockin/GEM Animals / List all strains in Protocol Application question 23 (or New Transgenic Strains Attachment for amendments)

1List ofCDC select agents

2WSU IBC Human Cell Lines Memo

II.CHEMICAL HAZARDS:

Does this research involvethe use of any hazardous chemicals, including chemotherapeutic drugs (e.g. STZ, doxorubicin) and gas anesthetic agents (e.g. isoflurane, halothane) or purified toxins (e.g. LPS, pertussis)?

NO
YES – (Chemical Hazards Definition and Examples) List below:

a.Hazardous chemicals administered to animals (potential DLAR staff exposure – AHAF II needed for hazards other than anesthetic agents):

b.Hazardous chemicals involved in this research used exclusively in the lab (no DLAR staff exposure):

c.Gas scavenging system?

NO
YES

i.If using anesthetic gases, indicate type of control measures:

Not Applicable
OR gas scavenging system / Chemical fume hood
Induction chamber with charcoalcanister/ scrubber / Other, specify:

III.RADIATION HAZARDS:

Does this research involvethe use of radioisotopes in vivo or the use of any irradiators or radiation generating machines?

NO
YES

a.Type:

Radioisotopes / Irradiators / X-ray Imager
Fluoroscopy / PET Scan / MRI Scan
CT Scan / Lasers / Other (specify):

b.List the isotope(s) and the activity to be used in vivo:

Not Applicable

c.Have you or your collaborator been authorized by WSU Radiation Safety Committee to use this isotope / equipment?

NO
YES If applicable, list collaborator:

d.Will DLAR staff be involved in the care of radioactive animals?

NO
YES

e. List the location(s) where the radioisotope work or the above listed equipment will be used:

IV.PHYSICAL/OTHER HAZARDS:

Does this research involve the use of any physical/other hazards (e.g. noise, nanoparticles, cryogens)?

NO
YES

a.Type:

Noise / Heat / Cryogenic liquids/ gases
Nanoparticles / Other (specify):

b. List the location(s) where the hazard will be used:

V.CONTROLLED SUBSTANCES:

Does this research involve the use of Controlled Substances (CS)? (DEA CS list: Controlled Substances - by CSA Schedule)

NO
YES –Specific Controlled Substances licenses and procedures are required. OEHS will contact you.

a.Do you have a state of Michigan issued Controlled Substances license and a DEA registration?

NO
YES

For the Office of Environmental Health and Safety (OEHS) use only – leave blank.

PROTOCOL NUMBER:

I.BIOLOGICAL HAZARDS:

Not Applicable (no biological hazards)

Does this protocol require IBC approval?

No
Yes
Approved
Pending
Comments:
Signature of Biosafety Officer – R. Pearson / Date

II.CHEMICAL HAZARDS:

Not Applicable (no chemical hazards)
Approved
Pending Approval (e.g. PI has not submitted SOPs)
Comments:
Signature of Chemical Hygiene Officer – I. Iban / Date

III.RADIATION HAZARDS:

Not Applicable (no hazards)

Does this protocol require RSC approval?

No
Yes
Approved
Pending
Comments:
Signature of Health Physicist – M. Srinivasan / Date

IV.PHYSICAL/OTHER HAZARDS:

Not Applicable (no physical hazards)
Approved
Pending (e.g. PI has not submitted SOPs)
Comments:
Signature of Chemical Hygiene Officer – I. Iban / Date

V.CONTROLLED SUBSTANCES:

Not Applicable (no CS)
Noted for CS Records
Comments:
Signature of Compliance Officer – R. Harrison / Date

VI.ANICON PROGRAM:

Approved (all research personnel have submitted questionnaire)
Pending
Comments:
Signature of Occupational Health Specialist – K . Cadwell / Date

OEHS DIRECTOR AUTORIZATION:

Signature of OEHS Associate Director – R. Moon / Date
This protocol involves hazards that require special animal handling precautions. An Animal Hazardous Agents Form Part II(AHAF II) has been completed for use by the DLAR and research personnel.

Form Approved: May 2014WSU Animal Hazardous AgentsForm Page 1 of 4