Cover Sheet

Subcommittee on Research Safety

NF/SG VHS Gainesville, FL (573)

Please complete form electronically.

VA PI:
Title of Protocol(as submitted to IRB or IACUC):
Human Study, IRB #: / Animal Study, ACORP #: / Non-Human/Non-Animal (Bench/Lab & Other)

Please check all items which are included in the attached packet. Please do not staple.

New Initial SRS Submission / SRS RenewalSubmission / SRS Amendment
(Note: amendments required for changes such asnew PI, staff, protocol, materials, animals, bio-hazards, samples, etc.)
Attached Forms:
Research Protocol Safety
Evaluation
Request for Annual Continuing
Safety Review
Research Protocol Safety
Amendment Form
Research Project Abstract
New, Update, Final
Research Project Protocol
New, Update, Final
Description/Justification
(NOTE: includes safety precautions/ procedures of changes) / UF IRB-01 Approval
Central IRB Approval
IACUC Approval
Radiation Safety Officer/Committee Approval Letter
Chemical Inventory List
New, Update
UF IBC approval letter
(for rDNA usage) / Other:
Other:
Other:
Other:
Other:

Incomplete submissions will be returned to the PI.

last revised: 06/08/2015

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Personnel and Training List

Instructions:

List all current PIs and staff members involved in the conduct of this research project.In the third column, please indicate all personnelwho are being either added to or removed from this study via this submission.

For each person listed, please use the checkboxes to indicate which trainings are required in association with their specific work on this protocol. Please verify before submitting to the SRS that the checked trainings have been completed.

Names
(Last, First) / *
Project Role / Personnel being added or removed? / Study qualifies forChair Review; no safety training is required. / **
“VA ORD Bio-Security”
CITI training / “Biohazard Shipping”
CITI training / “Bloodborne Pathogens”
CITI training / “Understanding Nanotechnology and Its Implications”
CITI training / List Other Safety Training
VA PI / new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project
new to projectREMOVED from project

* Project Roletitles: VA-PI, UF-PI, Co-PI, Investigator, Coordinator, CDA, Research Assistant, Lab Assistant, etc.Must match roles noted in the main study protocol.

All training indicated above must be completed and in current good standing.Incomplete submissions will be returned to the PI.

**VA ORD BioSecurity Training, Basic Course required for:

  • Human Studies:All study personnel (whether VA-employed or WOC) working in VA research labs, working with hazardous agents, working in BSL-2 labs, and all employees who have administrative duties associated with labs.
  • Animal Studies:All study personnel (whether VA-employed or WOC).
  • Courses must be completed within 30 days of hire.Training requirement is one-time only; annual refreshers are not required for this course.
  • Courses available at:

For a complete list of safety training requirements, see the Guidelines for Safety Training, on the Subcommittee onResearch Safety web page.

last revised: 06/08/2015

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