/ Animal Facility Annex
/ Biosafety Committee
Registration No.______
To be filled in by CBS

CEEA

Registration No.______

To be filled in by CBS

BIOSAFETY STATEMENT FOR EXPERIMENTAL PROCEDURES TO BE DEVELOPED AT THE ANIMAL FACILITY
BIOLOGICAL SAFETY INFORMATION FOR THE ANIMAL FACILITY
You must complete the following questionnaire if the experimental procedure takes place at the animal facility and involves the use of chemical products considered toxic or harmful and specified as such by the manufacturer or distributor, radioisotopes, carcinogenics or potentially carcinogenic products, and/or infectious biological agents.
1. Name of the principal investigator who states the declaration:
2. Centre to which he/she belongs:
3. Title of the experimental procedure:
4. Brief description of the agent (enclose product safety sheet):
5. The previous agent / material is potentially hazardous for (mark):
Only humans / Only animals / Humans and animals
Other (specify)
6. The agent can be transmitted by the following means (mark if yes):
Blood / Excrements / Urine / Saliva / Sputum
Other fluids (specify)
By a vector (specify)
It is not transmitted from an animal to another or to the environment
Other (specify)
7. On the following list, please indicate the safety measures you consider appropriate to take when working with the above mentioned agent:
Only lab workers are authorized to handle these animals
Autoclave the cages before cleaning
Label the cages identifying the biological risk
Identify and dispose the animal remains by:
Incineration
A sealed and autoclavable bag
Containers of biohazardous products
Other (specify):
8. Please specify the personal protective equipment to be worn by the animal facility technicians handling these animals (specify):
Dispose the material specified in the previous paragraph into an identified container inside the cabinet
Reject all the material when is finished handling
Sterilize the room when the assay is finished
All waste will be processed as hazardous chemicals
All waste will be processed as isotopic waste
9. Please write any other comment you may consider relevant regarding the biosafety measures to be taken:
10. In case of incident / accident / spillage please alert:
The undersigned, being the principal investigator of the procedure, declares that all information stated in this application form is complete and true. He/She also declares that he/she will apply the necessary biosafety measures and practices in accordance with legal regulations concerning the protection of human beings and the environment (Law 31/1995, RD 664/97, Law 9/2003 and RD 178/2004), and any significant change in the work conditions of this research procedure, will be communicated to the Biosafety Committee beforehand.
Date:
Signatureof the principal investigator who states the declaration:

Note: once filled in and signed, this application form will be sent to 1

Update09/16