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
on: ____________by: ___________________________________________
Removal Request Confirmed
on: ____________by: ___________________________________________
Notification Letter Sent
on: ____________by: ___________________________________________
Lock Change, if applicable
on: ____________by: ___________________________________________
Removal Amendment Sent
on: ____________by: ___________________________________________
Comments, if any: ________________________________________________________________________________
SAP Form 002 (Rev. 09/2015)