Aphis/cdc Form 3 - Report Of Theft, Loss, Or Release Of Select Agents And Toxins - Department Of Health And Human Services

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FORM APPROVED
REPORT OF THEFT, LOSS, OR RELEASE OF SELECT AGENTS
OMB NO. 0579-0213
OMB NO. 0920-0576
AND TOXINS (APHIS/CDC FORM 3)
EXP DATE 10/31/2014
INSTRUCTIONS
Detailed instructions are available at Answer all items completely and type or
print in ink. This report must be signed and submitted to either APHIS or CDC:
Animal and Plant Health Inspection Service
Centers for Disease Control and Prevention
Accession Number:
Agricultural Select Agent Program
Division of Select Agents and Toxins
4700 River Road Unit 2, Mailstop 22, Cubicle 1A07
1600 Clifton Road NE, Mailstop A-46
Riverdale, MD 20737
Atlanta, GA 30333
FAX: (301) 734-3652
FAX: (404) 718-2096
(For Program Use ONLY)
Email:
Agricultural.Select.Agent.Program@aphis.usda.gov
Email:
form3@cdc.gov
Submit completed form only once by either email, fax, or mail
SECTION 1 – TO BE COMPLETED BY ALL ENTITIES
1. Date of Incident:
2. Date of Immediate Notification:
3. Type of Immediate Notification:
Email
Fax
Telephone
4. Name of Entity (entities registered with CDC or APHIS)
or
5. Entity registration number (For select agent registered entities
Name of Hospital or Laboratory (non-registered entities):
only):
6. Physical Address:
7. City:
8. State:
9. Zip Code:
10. Responsible Official (registered) or Name of Laboratory Supervisor (non-registered):
11. Telephone #:
12. Fax #:
13. Email address:
14a: Type of Incident (Human Health):
15. Did the release result in a potential exposure?
Theft
Loss
Release
Lab Acquired Infection
No
Yes
N/A (If Yes , explain in Blocks 28 or 31)
14b: Type of Incident (Animal and Plant Health):
If yes, has medical surveillance been initiated?
Unintended Animal Infection
Unintended Plant Agent Release
No
Yes
N/A (If Yes , explain in Blocks 28 or 31)
14c: Transfer:
Transfer incident (complete Sections 1 and 2 and Appendix B)
16. Time incident occurred:
17. Location of incident (building and room #):
18. Location of incident within room (e.g., freezer, incubator,
centrifuge):
19. Biosafety level:
20. Date of last inventory (for reporting loss
21. Name of Principal Investigator:
only):
BSL2
BSL3
BSL4
ABSL2
ABSL3
ABSL4
PPQ Agent
BSL3 Ag
SECTION 2 – TO BE COMPLETED BY ALL ENTITIES
23. Characterization of Agent
22. Name of Select Agent or Toxin
24. Quantity / Amount
(e. g. strain, ATCC #)
A
B
C
Next Page

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