Aphis/cdc Form 3 - Report Of Theft, Loss, Or Release Of Select Agents And Toxins - Department Of Health And Human Services Page 2

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25. Provide a detailed summary of events including a timeline of what occurred. Whenever possible, conduct a risk assessment of the event and determine if the

root cause can be identified. State specifically what personal protective equipment was worn and what, if any, medical surveillance was provided or planned. If

incident involves a non-human primate, please state species.

Block 25. Continued: (Use Appendix A for continuation, if necessary)

SECTION 3 – TO BE COMPLETED BY ALL ENTITIES ONLY FOR RELEASE

OF SELECT AGENTS AND TOXINS OR OCCUPATIONAL EXPOSURE

26. An internal review of laboratory procedures and policies has been initiated to lessen the likelihood of recurrences of theft, loss or release of select agents and

toxins at this entity.

Yes

If yes, please provide additional details.

27. What were the hazards posed to humans by the extent of the release or occupational exposure?

28. What is the estimated extent of the release or exposure in relation to the proximity of susceptible humans, animals and plants?

29. Provide a brief summary of how the laboratory and work surfaces were decontaminated after the release.

30. In select agents and toxins posing a risk to humans, please state how many laboratorians were potentially exposed and provide a brief summary of the

medical surveillance provided (do not provide names or confidential information).

Certification: I hereby certify that the information contained on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a

false statement on any part of this form, or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of the

select agent regulations may result in civil or criminal penalties, including imprisonment. 7 CFR 331, 9 CFR 121, 42 CFR 73.

Signature of Respondent: _________________________________________________

Title: ____________________________________

Date Signed: _________________ ____________

Typed or printed name of Respondent: _______________________________________

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