Biosafety Permit Amendment Form
Applicant Information (Permit Holder)Last Name (Print): / First Name (Print):
NSID:
Permit Number:
Department:
Office Telephone Number:
Laboratory Telephone Number:
Email Address:
Alternate Contact Person Information (Only complete if making changes to alternate contact)
Last Name (Print): / First Name (Print):
NSID:
Department:
Office Telephone Number:
Laboratory Telephone Number:
Email Address:
Animal Care Protocol Approval
(if working with animals) / ☐Yes ☐No ☐N/A / Human Ethics Protocol Approval / ☐Yes ☐No ☐N/A
Type of Permit Amendment / Requirements / Check which is applicable:
Addition of new research project/protocol / Update/complete Section 2 of Biosafety Plan Template
Develop new SOPs that are specific to the research project/protocol and revise Section 7 of theBiosafety Plan Template / ☐ /
Major change to existing research initiative(s)/project(s)- Addition / Update/complete Section 2 of Biosafety Plan Template
Update any SOPs that are specific to the research project/protocol and reviseSection 7 of Biosafety Plan Template / ☐ /
Addition/Changes to organisms, biological materials, or Biohazardous materials / Update/complete Sections 2, 3, 4,5 and 6of the Biosafety Plan Template
Develop new SOPs that are specific to the use of the new biological material and revise Section 7 of Biosafety Plan Template
If the biological material is procured from off campus (domestic/international source), a Biological Agent Transfer Notification Form( be completed / ☐ /
Addition/changes of recombinant DNA (rDNA), genetically modified organisms (GMO), and/or transgenic animals/plants / Update/ complete Sections 2, 3, 4, 5 and 6of the Biosafety Plan Template
Develop new SOPs that are specific to the use of the new biological material and revise Section 7 of the Biosafety Plan Template
Complete the Risk Assessment for rDNA-GMMO-TransgenicsForm(
Provide a copy of the vector map
If the biological material is procured from off campus (domestic/international source), a Biological Agent Transfer Notification Form( be completed / ☐ /
Changes to the volume, quantity, or concentration of the biological materials listed on the permit / Update/complete Sections 2,3, and 4 of Biosafety Plan Template / ☐ /
Additions/Deletions to authorized worker(s) listed on the permit / Ensure individual(s) have current Biosafety training (training expires after 3 years)
Individual(s) must complete and submit a BiosafetyAuthorized Worker Training Record(
Provide list of individuals (names) who will be added and/or removed from the permit and their NSIDbelow / ☐ /
Changes to permit contact information / State the change in contact information below
If an new alternative contact is designated, fill out the information in the space “Alternate Contact Information” above
Update/complete Section 1 of Biosafety Plan Template / ☐ /
Additions/Changes to location(s) / State the building name and room number below
Update/complete Section 6of Biosafety Plan Template / ☐ /
Change in Permit Holder
NOTE: This option is for permit holders who have immediate left the University with no notice or who have passed away only. / Ensure individual(s) have Current Biosafety training (training expires after 3 years)
Individual(s) must complete and submit a Biosafety Authorized Worker Training Record(
Provide list of individuals (names) who will be added and/or removed from the permit and their NSID / ☐ /
EXPIRE Biosafety Permit / State that permit needs to be expired below
If the biological material is transferred to another location or individual provide the name and/or location below
If the material is disposed of, state method and date of disposalbelow
Follow theDecommissioning Standard ( / ☐ /
Provide a brief description of the proposed permit amendment andattach any necessary information required for the amendment:
The information provided in this application and supporting documentation is complete and accurate to the best of my knowledge:
Signature of Applicant:
Date:
Biosafety OFFICE ONLY: / All documents and supporting information for
permit amendment received and reviewed. / Facility and biosafety plan elements verified
during site visit
Final Approval Provided by the Biosafety
Officer or the Biosafety Protocol Approval
Committee / Date:
Signature:
Safety Resources
September 20171 | Page