Application for approval to use biologically hazardous material(s) for research purposes
INSTITUTIONAL BIOSAFETY COMMITTEE
Biologically hazardous materials are defined as pathogenic organisms or materials that have the potential to transmit pathogenic organisms or biotoxins to humans, animals or the environment, and therefore require special precautions to be taken in their use, transport or storage.
This application form should be completed for approval to use a biologically hazardous material in Risk Group 2(AS/NZS 2243.3:10 – Safety in laboratories – Microbiological safety and containment) to be undertaken by University Personnel or to be undertaken by other personnel within University premises. The relevant Standard can be located in the SAI Global Online Database, accessing via the UniSA Library.
Completed forms should be submitted to:
If you require assistance completing this form, please contact the Chair of the IBC, A/Prof. John Hayball () or the IBC Executive Officer ().IBC use / IBC Reference Number
1 / Project title
Proposed commencement date
Expected completion date
Please note that ethics approval can only be given for a maximum of three years. If the project is expected to exceed this time limit, a further application will need to be submitted prior to the 3 year expiry date.
2 / Individuals who will be handling the biologically hazardous material(s)
Investigators / 1st Chief Investigator / Other Investigator / Other Investigator
Title, Initial(s) and Surname
Current appointment
School/Institute/Centre/Other
Is this person / Male Female / Male Female / Male Female
Will any students be using the biologically hazardous material(s)? / No
Yes / If yes, please attach a list of Student names, including Student ID number.
3 / Justification
Clearly justify why the biologically hazardous material is to be used(no more than 200 words/15 lines of text).
NOTE: IBC Assessors are from a range of University disciplines and require adequate detail to understand what your specific project will involve.
4 / Hazard details
Please include the details for all biologically hazardous material for which the Chief Investigator is seeking approval for use
Material Identification
(Culture collection number or similar if available) / Risk Group 2 Organism or Toxin / Potential (P) or
Actual (A) Hazard?
5 / Pathogenicity details
Please include a description of the pathogenicity of the biologically hazardousmaterial to be used
6 / Infectious agent details
Is the biological hazard listed as a SSBA under Part 3 of the National Health Security Act 2007 ()?
Yes
No / If yes, please contact A/Prof John Hayball () prior to submitting this form.
7 / Use, safety and disposal
What facilities are available for the safe handling of the biologically hazardous material(s)? (No more than 200 words/15 lines of text)
What specific safety precautions will be taken?(No more than 200 words/15 lines of text)
Describe any preventative measures that will be undertaken (for example vaccination)?(No more than 200 words/15 lines of text)
How will the biologically hazardousmaterial(s) and their products be disposed of? (No more than 200 words/15 lines of text)
References relevant to the dangers or safe use of the material(s) to be used (no more than 200 words/15 lines of text –please attach a separate list if necessary).
8 / Facilities to be used
Clearly identify the laboratories (including room numbers) where the biologically hazardous material(s) will be used and where stored
Facility 1 / Facility 2 / Facility 3
OGTR Certified / Yes No / Yes No / Yes No
OGTR Certification No.
Room Number(s)
Building
Type of Facility
Facility Contact
Aspects of hazard to be performed in this facility
Facility 4 / Facility 5 / Facility 6
OGTR Certified / Yes No / Yes No / Yes No
OGTR Certification No.
Room Number(s)
Building
Type of Facility
Facility Contact
Aspects of hazardto be performed in this facility
Will the dealing involve storage of the Biological Hazard outside of a facility listed above? / Yes No
If yes, where?
9 / Compliance Declaration
I certify that I am aware of and have access to the Australian/New Zealand Standard 2243.3:10 (Safety in laboratories – Microbiological safety and containment); that I will take responsible care with the use of biologically hazardous material(s) specified in this application, and that all staff and students involved will be properly instructed in the safe use and disposal of suchmaterial(s).
Chief Investigator Name / Chief Investigator Signature / Date / /
10 / Facility Manager Declaration
As Facility Manager I have been informed of the nature of and risks involved with this biological hazard(s) and after consideration of them, I hereby consent to the work being performed in the listed facility.
I will ensure that the appropriate safety procedures are followed and that personnel are appropriately trained prior to undertaking work in the listed facility.
In the event of an incident or accident I am aware that I must put into place the appropriate responses, and I will inform the IBC as soon as practicable of any incidents or accidents.
Facility Manager Name - Facility 1 / Facility Manager Signature – Facility 1 / Date / /
Facility Manager Name - Facility 2 / Facility Manager Signature – Facility 2 / Date / /
Facility Manager Name - Facility 3 / Facility Manager Signature – Facility 3 / Date / /
Facility Manager Name - Facility 4 / Facility Manager Signature – Facility 4 / Date / /
Facility Manager Name - Facility 5 / Facility Manager Signature – Facility 5 / Date / /
11 / Head of School Declaration
As the Senior Manager responsible for the research activities of the Chief Investigator, I have been informed of the nature of and risks involved with this biologically hazardous material(s). I certify that appropriate facilities and procedures are in place for the safe use of the material(s) specified and I hereby consent to the work.
Head of School Name / Head of School Signature / Date / /
UniSABiological Hazards Application Form Last updated April 2014Page 1 of 4