Sap Form 002 Select Agent Program Participant Removal Request And Inventory Attestation Form

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Select Agent Program Participant Removal Request and Inventory Attestation Form

Submit requests to the RO at

nihselectagentprogram@od.nih.gov

or fax to

301-480-0701

Date: _________________

Removal Initiated by RO/ARO

1. Person Requesting Removal:

Full Name:____________________________________

Job Title: _________________________________________

2. Person to be Removed from SAP:

Full Name: ____________________________________ Job Title: _________________________________________

Desired Removal Date: __________________________

3. Reason for Removal:

Participant no longer requires unescorted access to select agents/toxins due to (select one):

change in job duties

termination of employment at NIH

A) Last date at NIH: _______________________________________________________________

B) Next place of employment: _______________________________________________________

Other: ______________________________________________________________________________________

4. Person being removed is a(n) (select one):

Laboratorian

Animal Care Staff

Support Staff

Unescorted Visitor

5. Attestation (must be completed by Requester in Section 1; select one):

I, _________________________________________________________ attest that,

the individual listed above did not have access to select agents/toxins or select agents infected animals.

the individual listed above had access to select agents/toxins and is no longer in possession of select agents/

toxins under my registration & all select agents/toxins used by the individual is accounted for in the inventory.

the individual listed above had access to select agent infected animals and all animals have been accounted for.

Place Signature Here

RESET FORM

** For Select Agent Program Office Use Only **

Attestation Completed? (#5): checked on: ____________checked by: ____________________________________

Removal Request Sent