Yellow Fields- Completed by the PI When Working in Laboratories That Require BSL1 Or Above

Revised 02/21/2017

Part IV - Personnel Information

Personnel List

Yellow fields- Completed by the PI when working in laboratories that require BSL1 or above.

Blue fields - Research Compliance will run the Visual Compliance Restricted Party Screening(s) (RPS) for any Non-U.S. personnel.

The PI will need to check their Technology Control Plan(s) (TCP) for the equipment, software, and labs to be accessed to see if the country of citizenship triggers any restrictions. Every College and non-academic department has a Visual Compliance Delegate to assist, as well as the ability to ask Research Compliance or the Office of Compliance.

EXAMPLE / ☐Add ☐Delete ☐Modify
First Name / Vladimir / Last Name / Putin / Title / President, Russian Federation
Email / / UIN/K# / CITI Exp / 01/01/2020 / OHP Exp / 01/01/2018 / Other / N/A
Citizenship Country / Russian Federation / RPS Date / 02/03/2017
Match / Restrictions / Yes – see TCPs for what is controlled. (Technology Control Plans)
Building(s) / Kleberg Hall / Room#(s) / 117
Companion IRB / IACUC Protocols / 2017-01-31 – IRB
2017-02-01-A1 IACUC / List all organism(s), pathogens, toxins, rDNA to be accessed / e. coli, human blood
1 / ☐Add ☐Delete ☐Modify
First Name / Last Name / Title
Email / UIN/K# / CITI Exp / OHP Exp / Other
Citizenship Country / RPS Date / Restrictions
Building(s) / Room#(s)
Companion IRB / IACUC Protocols / List all organism(s), pathogens, toxins, rDNA to be accessed
2 / ☐Add ☐Delete ☐Modify
First Name / Last Name / Title
Email / UIN/K# / CITI Exp / OHP Exp / Other
Citizenship Country / RPS Date / Restrictions
Building(s) / Room#(s)
Companion IRB / IACUC Protocols / List all organism(s), pathogens, toxins, rDNA to be accessed
3 / ☐Add ☐Delete ☐Modify
First Name / Last Name / Title
Email / UIN/K# / CITI Exp / OHP Exp / Other
Citizenship Country / RPS Date / Restrictions
Building(s) / Room#(s)
Companion IRB / IACUC Protocols / List all organism(s), pathogens, toxins, rDNA to be accessed
4 / ☐Add ☐Delete ☐Modify
First Name / Last Name / Title
Email / UIN/K# / CITI Exp / OHP Exp / Other
Citizenship Country / RPS Date / Restrictions
Building(s) / Room#(s)
Companion IRB / IACUC Protocols / List all organism(s), pathogens, toxins, rDNA to be accessed
5 / ☐Add ☐Delete ☐Modify
First Name / Last Name / Title
Email / UIN/K# / CITI Exp / OHP Exp / Other
Citizenship Country / RPS Date / Restrictions
Building(s) / Room#(s)
Companion IRB / IACUC Protocols / List all organism(s), pathogens, toxins, rDNA to be accessed

(Please reproduce this page and renumber fields as needed.)

Signature Page

Each employee working in laboratories classified as BSL1 and above must complete this page.

By my signature below, I certify that I have read and understand the laboratory security and emergency policies and procedures for working with in laboratory building and room(s) under the direction of.

I further certify that I understand the hazards of working with ; the indications of infection or intoxication by this biological material; the reporting system for potential exposure and accidents; how to seek evaluation and therapy; the standard microbiological practices for this laboratory; the special Biosafety practices required for Biosafety level work, in accordance with the Biosafety in Microbiological and Biomedical Laboratories (BMBL) Guidebook and the standard operating procedures for this laboratory.

Finally, I certify that any transfer of this biological material will be done in accordance with Texas A&M University-Kingsville policies and procedures and under the supervision of the Texas A&M University-Kingsville Environmental Health and Safety Office. In addition, I ensure that the detailed records of information necessary to account for all activities related to this agent will be maintained.

Have you completedthe required CITI training for this research? ☐Yes / ☐No

______

Date of CITI Training (attach CITI certificate and certificates, if available, for any other training taken)

Have you completedOccupational Health Enrollmentfor this research? ☐Yes / ☐No

______

Date of Occupational Health Enrollment

______

Personnel SignatureDate

______

Personnel Printed NamePersonnel Position / Title

______

Lab director/Supervisor’s signatureDate

______

Lab director/Supervisor’s Printed NameLab director/Supervisor’s Position / Title

(Please reproduce this page as needed for each faculty, staff, or student listed on the protocol)

TAMUK IBC Protocol Amendment - Personnel Page 1