Fillable 6a - Potentially Hazardous Biological Agents Risk Assessment Form printable pdf download

Potentially Hazardous Biological Agents Risk Assessment Form (6A)

Required for research involving microorganisms, rDNA, fresh/frozen tissue (including primary cell lines, human and

other primate established cell lines and tissue cultures), blood, blood products and body fluids.

SRC/IACUC/IBC approval required before experimentation.

Student’s Name(s)

Title of Project

To be completed by the QUALIFIED SCIENTIST/DESIGNATED SUPERVISOR in collaboration with the student researcher(s).

All questions are applicable and must be answered; additional page(s) may be attached.

SECTION 1: PROJECT ASSESSMENT

1. Identify potentially hazardous biological agents to be used in this experiment. Include the source, quantity and the biosafety level

risk group of each microorganism.

2. Describe the site of experimentation including the level of biological containment.

3. Describe the procedures that will be used to minimize risk (personal protective equipment, hood type, etc.).

4. What final biosafety level do you recommend for this project given the risk assessment you conducted?

5. Describe the method of disposal of all cultured materials and other potentially hazardous biological agents.

SECTION 2: TRAINING

1. What training will the student receive for this project?

2. Experience/training of Designated Supervisor as it relates to the student’s area of research (if applicable).

SECTION 3: For ALL CELL LINES and MICROORGANISMS – To be completed by the QUALIFIED SCIENTIST or DESIGNATED

SUPERVISOR - Check the appropriate box(es) below:

Experimentation on the cell line/microorganism used in this study was not conducted at a Regulated Research Institution, but was conducted at

a (check one) ___BSL-1 or ___BSL-2 laboratory. This study has been reviewed by the local SRC and the procedures have been approved prior to

experimentation.

Experimentation on the cell line/microorganism used in this study was conducted at a Regulated Research Institution and was approved by the

appropriate institutional board prior to experimentation; institutional approval forms are attached.

Origin of cell lines:__________________________________________

Date of IACUC/IBC approval (mm/dd/yy) ___________________________

Experimentation on the cell line/microorganism used in this study was conducted at a Regulated Research Institution, which does not require

pre-approval for this type of study. The SRC has reviewed that the student received appropriate training and the project complies with Intel

ISEF rules.

CERTIFICATION – To be SIGNED by the QUALIFIED SCIENTIST or DESIGNATED SUPERVISOR

The QS/DS has seen this project’s research plan and supporting documentation and acknowledges the accuracy of the information pro-

vided above. This study has been approved as a (check one) o BSL-1/ o BSL-2 study, and will be conducted in an appropriate laboratory.

QS/DS Printed Name

Signature

SECTION 4: CERTIFICATION – To be completed by the LOCAL or AFFILIATED FAIR SRC

The SRC has seen this project’s research plan and supporting documentation and acknowledges the accuracy of the information

provided above.

SRC Printed Name

Signature

Page 40

International Rules: Guidelines for Science and Engineering Fairs 2016 –2017,

6a - Potentially Hazardous Biological Agents Risk Assessment Form