Aphis/cdc Form 3 - Report Of Theft, Loss, Or Release Of Select Agents And Toxins - Department Of Health And Human Services Page 5

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APPENDIX B

IF THE INCIDENT OCCURRED DURING TRANSFER, COMPLETE SECTIONS 1 AND 2 OF FORM 3 AND PROVIDE THE

FOLLOWING INFORMATION (INCLUDE A COPY OF THE RELEVANT APHIS/CDC FORM 2)

1. Transfer authorization number from APHIS/CDC Form 2:

2. Date Shipped:

3. Name of Carrier:

4. Airway bill number, bill of lading number, tracking number:

5. Package Description (size, shape, description of packaging including number and type of inner packages; attach additional sheets as necessary):

6. Package with select agents and toxins received by

7. Package with select agents and toxins appears to have been opened:

requestor:

Yes

If yes, date of receipt:

Yes

If yes, include explanation in box 5 above.

8. Sender was contacted regarding incident:

9. Carrier/courier was contacted regarding incident:

Yes

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: _______________________________________

Public reporting burden: Public reporting burden of providing this information is estimated to average 1 hour per response, including the time for reviewing instructions, searching

existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person

is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect

of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D74, Atlanta, Georgia 30333;

ATTN: PRA (0920-0576).

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