Research Registration Form
Program Areas

Biological Safety

Campus Safety

Education and Training

Environmental Health

Fire Prevention

Hazardous Waste Management

Industrial Hygiene

Radiation Protection

 

 

  

1. CONTACT INFORMATION
First Name (Principal Investigator) Last Name
Office Phone Number Lab Phone Number
Room Number  
Department Other Department:
 
Building Other Building:
Funding Source

2. PROJECT INFORMATION
Title of Research Project:
Please attach a brief protocol of the research and include the purpose, risks to personnel, and outline of procedures, methods of inactivation or disposal.
Does this project involve any of the following?
a. Radioactivity YES NO
b. Human subjects YES NO
c. Hazardous, Toxic, Carcinogen, or Mutagenic Chemicals YES NO
d. If Carcinogens, list chemicals

3. ANIMAL   YES NO

a. Is pathogen inserted into animal? YES NO
b. Animal genus/species
c. Animal housing location
d. IACUC protocol number

4. PATHOGENIC    YES NO

a. What pathogenic microorganism(s) or toxin(s) is used?
b. Is this organism or toxin on the CDC list of Select Agents?
YES NO N/A
c. Do you work with this organism or toxin in quantities greater than 1 liter?
YES NO N/A
d. Do you concentrate the organism or toxin?
YES NO N/A
e. Medical Information (If the microorganism is a human pathogen, please answer the following questions.)
  Is a vaccine available? YES NO N/A
  Will baseline serum samples be taken? YES NO N/A
  If accidental infection occurs, what treatment is available for the disease?
 
 

5. HUMAN BLOOD, BODY FLUID, CELLS, OR TISSUE  YES NO

a. Human Cells YES NO
b. Human Blood YES NO
c. Human Tissues YES NO
d. Other
e. Have lab personnel been immunized for hepatitis B? YES NO N/A
 

6. SAFETY INFORMATION
a. Are hypodermic needles and/or other sharps used in the laboratory?
YES NO N/A
b. Is personal protective equipment available for personnel (for example: gloves, goggles, lab coats, other)?
YES NO N/A
c. Please outline any special precautions that will be taken in your laboratory to protect personnel from accidental exposure to bio-hazardous agents.
d. How do you decontaminate and dispose of  bio-hazardous waste?
  Autoclave YES NO N/A
  Chemical Disinfection YES NO N/A
   Incineration YES NO N/A
e. Physical containment level required/recommend by NIH Guidelines
BL1 BL2 BL3 BL4
f. Is medical surveillance required?
YES NO
g. If yes, identify personnel to be included?
 
h. List all personnel involved in this project who may be at risk to potential exposure. Include lab technicians, animal caretakers, and students.
i. Who should be called during an emergency? Include name, office telephone number, and home telephone number.
Contact 1:
Contact 2:
Contact 3:
I accept responsibility for the safe conduct of this work (at Bio-safety Level ) I have informed the personnel in my laboratory of the conditions of this work. * This document will be reviewed by the UMASS Biohazards Committee.

By completing and submitting this document you are here by verifying the above information is accurate and true.