Contact Information Association with UNTHSC Company Name
Research Group
Experimental Locations Leased Space
Shared Space
Laboratories to be accessed Primary Contact Name
First
Last
Primary Contact Phone
Primary Contact Email
Experiment Overview
Please provide a brief overview of the work you intend to do in the Discovery Center labs. If the work is a part of a study covered by an approved IBC/IACUC/IRB protocol, please provide the approval number or attach the approved application. Please include in your overview an indication of the lab equipment you expect to use. Please also include a summary of precautions you will take to limit potential risk and exposure to other lab users, i.e. mitigating aerosol production, transporting samples to the lab, etc.
Biological Agents Please list all biological agents that will be used in the Discovery Center labs. (Not necessary if detailed in an approved IBC application.)
Number of Biological Agents that will be used: Must be a number less than or equal to 10.
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Item # Name of Material
If agent, list genus & species. If toxin, include agent (genus & species) it is derived from. If rDNA list genus and species of all organisms involved.
Type Strain of Agent (if applicable)
Source
Please specify the type and name of source (e.g., vendor – ATCC; off-campus collection – Univ. of CA; clinical specimen - human).
Risk Group
Biosafety Label (BSL)
Note / Storage Location
Chemical Agents List all hazardous chemical agents that will be used in the facilities, i.e. those with a National Fire Protection Association (NFPA) rating of 3 or above in any of the categories on the NFPA diamond or any special coding in the white quadrant. As per your Program Participation agreement, all hazardous chemicals must be approved by the UNT Health Science Center before they are brought onto the premises. Material Safety Data Sheets should be provided to the Laboratory Manager when such chemicals are brought into the facilities.
Number of Chemical Agents that will be used: Must be less than or equal to 10.
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Item #
Name of Material
State CAS #
Anticipated Amount
NFPA Hazard Rating: Health 0 1 2 3 4
NFPA Hazard Rating: Flammability 0 1 2 3 4
NFPA Hazard Rating: Reactivity 0 1 2 3 4
Other/Specific Hazards
Please give any specific hazard information for your chemical. Examples include oxidizer, acid, alkali, corrosive, use no water and polymerizes.
Notes
Waste Management / Equipment Waste Management
Please provide a brief overview of how you will handle any chemical or biological waste generated by your lab activities.
Equipment
Please list significant lab equipment you expect to use in the facilities.
Personnel How many people are in your group?
Group Member 1 Name
First
Last
Group Member 1 Email
Group Member 1 HBV Vaccination Group Member 2 Name
First
Last
Group Member 2 Email
Group Member 2 HBV Vaccination Group Member 3 Name
First
Last
Group Member 3 Email
Group Member 4 Name
First
Last
Group Member 4 Email
Group Member 4 HBV Vaccination Group Member 5 Name
First
Last
Group Member 5 HBV Vaccination Group Member 5 Email
Group Member 6 Name
First
Last
Group Member 6 HBV Vaccination Group Member 6 Email
Group Member 7 Name
First
Last
Group Member 7 HBV Vaccination Group Member 7 Email
Group Member 8 Name
First
Last
Group Member 8 HBV Vaccination Group Member 8 Email
Group Member 9 Name
First
Last
Group Member 9 HBV Vaccination Group Member 9 Email
Group Member 10 Name
First
Last
Group Member 10 HBV Vaccination Group Member 10 Email
Every person gaining access to the Discovery Center will need to sign and complete a policies form, indicating that UNTHSC Policies and Procedures will be adhered to.
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