Internal DURC Report Form

Instructions: If you have, or plan to obtain, one of the agents or toxins listed on this form then you must complete this form and submit it to the ICDUR through the Export Compliance Office (ECO) at .

PI Name: / Department:
Phone: / E-Mail:
General Questions:
RAMSPOT FP# (if applicable):
Location of laboratory for this project:
What source is providing the funding for the project?
Have you had a prior DURC review conducted by the IRE for this project? ☐Yes ☐No
DURC Agents and Toxins : / (Check all non-attenuated agents or toxins involved in this project)
☐ / Avian influenza virus (highly pathogenic)
☐ / Bacillus anthracis
☐ / Botulinum neurotoxin (any quantity)
☐ / Burkholderia mallei
☐ / Burkholderiapseudomallei
☐ / Ebola virus
☐ / Foot-and-mouth disease virus
☐ / Francisellatularensis
☐ / Marburg virus
☐ / Reconstructed 1918 influenza virus
☐ / Rinderpest virus
☐ / Toxin-producing strains of Clostridium botulinum
☐ / Variola major virus
☐ / Variola minor virus
☐ / Yersinia pestis
DURC Experimental Effects: / (Indicate whether the research involving the DURC agents and toxins checked above produces, aims to produce, or can be reasonably anticipated to produce any of the following experimental effects. Provide an explanation as to why or why not.)
☐ YES / ☐ NO / Enhances the harmful consequences of the agent or toxin.
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☐ YES / ☐ NO / Disrupts immunity or the effectiveness of an immunization against the agent or toxin without clinical or agricultural justification.
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☐ YES / ☐ NO / Confers to the agent or toxin resistance to clinically or agriculturally useful prophylactic or therapeutic interventions against the agent or toxin or facilitates its ability to evade detection methodologies.
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☐ YES / ☐ NO / Alters properties of the agent or toxin in a manner that would enhance its stability, transmissibility, or ability to be disseminated.
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☐ YES / ☐ NO / Alters the host range or tropism of the agent or toxin.
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☐ YES / ☐ NO / Enhances the susceptibility of a host population to the agent or toxin.
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☐ YES / ☐ NO / Generates or reconstitutes an eradicated or extinct agent or toxin listed in in this form.
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I attest that, to the best of my ability, I have truthfully answered all of the above questions. I have full knowledge of the scope of research work discussed in this form, AND

I agree to notify the IRE of any changes in my research that may involve one of the 7 DURC experimental effects.

PI SignatureDate

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Export Compliance Office 4-28-2017