1. Are biological agents or materials used or stored at your facility? (examples of biological agents or materials include microorganisms, parasites, invertebrates, plants, animals, and animal carcasses/tissues) ✻
2. Have Principal Investigators surveyed the contents of all freezers and storage assigned to them? ✻
3. Do Principal Investigators at your facility conduct work with genetically-modified organisms or pathogens? ✻
3a. If you answered yes to question 3, do the Principal Investigators have Biological Use Authorizations (BUA) on file with their affiliated campus Institutional Biosafety Committee (IBC)? ✻
4. Do Principal Investigators at your facility currently have any agents or toxins from the Federal Select Agent list? ✻
4a. If you answered "Yes" to question 4, please specify which Select Agents or Toxins are present at your facility and in what quantity?
5. Are you aware of any abandoned freezers or stored biological agents at your facility? ✻
5a. If you answered "Yes" to question 5, please provide the location or description of the abandoned materials. (Facility, Building, Room, Labeling, etc. )
Certification of Responsible Party
I certify (or declare), as the director of the facility or research center noted below, that the contents and responses contained herein are true and correct. If additional or erroneous information is discovered at a later date, EHS will be notified in writing and a revised survey will be submitted. ✻
Location: ✻
If your facility is not listed in the dropdown menu above, please indicate your facility or location here:
Director's Name (Last Name, First Name) ✻
Director's campus email ✻
