ࡱ> svr HbjbjWW >j550$$$$$8888pD 8!:4> $11!3!3!3!3!3!3!$"%W!$EEEW!$$l!333E$$1!3E1!33:,u Ѝ$PF !!0!# R2&2&u 2&$u EE3EEEEEW!W!EEE!EEEE2&EEEEEEEEE : INTERNAL PERMIT APPLICATION FOR BIOHAZARDOUS MATERIAL/SUBSTANCE USE A Risk Assessment is required with this application and will be scheduled with the BSO. Applications will be evaluated by the Laboratory Safety Committee. This is internal use only permit. Other permits through the Government of Canada may still be required. Please refer to the Application Procedures for more information.  General Information Project Title:Principal Investigator Department/programPosition/RankApplication DatePhone/FaxEmailProposed Start DateProposed End DateFunding Agency Name and title of personnel using Biohazardous Materials/Substances under this permit. Name Title Phone  Successfully completed Biosafety 2 Course? Date? Is Additional Training Required? Use of Biohazardous Material/Substance Name of Agent and Strain (s) *please attach PSDS Risk Group **Used in Vivo?  Used in Vitro? Supplier AmountIf you are using human blood, bodily fluids or tissues, describe below the sources of human material to be used in the project and any information relevant to determining its infectious potential.  FORMCHECKBOX  N/AWill these materials be obtained from people known to be infected with agents from Risk Group 2 or higher?  FORMCHECKBOX  N/A**All work using live animals must have Animal Care and Use Committee (ACUC) approval. Do you have an approved ACUC protocol? If so, please provide your protocol number. ________________________ Statement of intended use(s) Specify exact use/procedures involved regarding each Biohazardous Material/Substance.  Use, Inventory and Storage Specify laboratory location(s) where the biohazardous material will be handled:Where do you intend to store the biohazardous material/substance when not in use? Must be located in a secure area with limited to access of unauthorized personnel. Indicate the procedures regarding inventory control for this item? Please note: A copy of your inventory documentation will be required upon renewal of this application.Indicate how the material will be disposed of? Declaration: I, the undersigned, will ensure that all biohazardous materials/substances used in this project will be used for and in accordance with the guidelines of the Biosafety Manual, Biosafety Policy and the requirements of the relevant international, federal, provincial and municipal legislation. I accept responsibility for keeping the information in this application current and accurate and for notifying the Laboratory Safety Committee of any deviations from this proposal. Permit holder is responsible for ensuring compliance with the policies and procedures of the University of Northern British Columbia as well as with the requirements of the Public Health Canada and Canadian Food and Inspection Agency. ________________________________________ ___________________ Principal Investigator Signature Date Signature of Department Head indicating permission _______________________________ ____________________________ ____________________ Signature Print Name Date Please submit the completed application to the Biosafety Officer (BSO). To be completed by the Biosafety Officer: Risk Group ____________ Date of Risk Assessment __________________________ Date of Review/Approved by Laboratory Safety Committee _____________________ Requires completion of Government of Canada CL2 Checklist?  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