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Page 1 CDC SELECT AGENT SURVEY Principal Investigator/Name_____________________________ Date ___________________ Department ___________________________Room #____________Phone_________________ Title of Project: ________________________________________________________________ Please check one of the following: ____ I have reviewed the list of select agent microorganisms and toxins and I do not possess or use any of these agents. ____ I do possess and/or use one or more of the select agents and have checked the agents I possess below. ____ I do not currently possess or use any of the select agents but plan to do so in the future. I have indicated those I plan to use below. CDC Select Agents (Appendix A to 42 CFR Part 73) Viruses ____ 1. Cercopithecine herpesvirus 1 (Herpes B Virus) ____ 2. Crimean-Congo haemorrhagic fever virus ____ 3. Eastern Equine Encephalitis virus ____ 4. Ebola viruses ____ 5. Equine Morbillivirus ____ 6. Lassa fever virus ____ 7. Marburg virus ____ 8. Monkeypox Virus ____ 9. Nipah and Hendra Complex viruses ____ 10. Rift Valley fever virus ____ 11. South American Haemorrhagic fever viruses (Junin, Machupo, Sabia, Flexal, Guanarito) ____ 12. Tick-borne encephalitis complex viruses ____ 11. Variola major virus (Smallpox virus) ____ 12. Venezuelan Equine Encephalitis virus ____ 13. Viruses causing hantavirus pulmonary syndrome ____ 14. Yellow fever virus Bacteria ____ 1. Bacillus anthracis ____ 2. Brucella abortus, B. melitensis, B. suis ____ 3. Burkholderia (Pseudomonas) mallei ____ 4. Burkholderia (Pseudomonas) pseudomallei ____ 5. Clostridium botulinum C:\Documents and Settings\TEMP\Desktop\Policies_forms2009\newpolicies_forms_web2010\Pre- Award\BMC-grants-CDCselectagtsurvey.doc Page 2 ____ 6. Francisella tularensis ____ 7. Yersinia pestis Rickettsiae ____ 1. Coxiella burnetii ____ 2. Rickettsia prowazekii ____ 3. Rickettsia rickettsii Fungi ____ 1. Coccidioides immitis ____ 2. Coccidioides posadasii Toxins ____ 1. Arbin ____ 2. Aflatoxins ____ 3. Botulinum toxins ____ 4. Clostridium perfringens epsilon toxin ____ 5. Conotoxins ____ 6. Diacetoxysirpenol ____ 7. Ricin ____ 8. Saxitoxin ____ 9. Shigatoxin ____ 10. Staphylococcal enterotoxins ____ 11. Tetrodotoxin ____ 12. T-2 toxin Attenuated Select Agents (Genetic Elements, Recombinant Nucleic Acids and Recombinant Organisms) ____ 1. Select agent viral nucleic acids (synthetic or naturally derived, contiguous or fragmented, in host chromosomes or in expression vectors) that have potential to encode infectious and/or replication competent forms of any of the select agent viruses. ____ 2. Nucleic Acids (synthetic or naturally derived, and that are in a vector or host chromosome; can be expressed in vivo or in vitro; or are in a vector or host chromosome that can be expressed in vivo or in vitro) that have the potential to encode for the functional form(s) of any of the toxins from the select agents listed above, OR their toxic sub-units. ____ 3. Any of the viruses, bacteria, fungi, and toxins listed above that have been genetically modified. PI Signature: _______________________________________________________________ **** Mail completed survey to EHS at Fuller Building 470 or fax to 638-8822 **** C:\Documents and Settings\TEMP\Desktop\Policies_forms2009\newpolicies_forms_web2010\Pre- Award\BMC-grants-CDCselectagtsurvey.doc .

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