If You Have Significant Changes in Procedures And/Or Organisms, Please Submit a New BUA

Biosafety Registration Form AMENDMENT

If you have significant changes in procedures and/or organisms, please submit a new registration form. Please note that authorizations expire two years from the original approval date.

Today’s Renewal Auth date: date: No.: P.I.: Email: Phone: Lab Email: Phone: Contact: Departmen Buildin Room t: g: No.:

Is the project active? (If the answer is no, don’t continue filling out this form.) Ye N s o

Please enter the project’s title. Animal care protocol # (If applicable.) Are there any changes in project location? (If the answer is yes, please list Ye N the changes below.) s o Add Delet Building Name and Room Number e

Are there changes in the organisms/ biological materials? (If the answer is Ye N yes, please list the changes below.) s o Add Delet Organism Biosafety Level e 1 2 3 1 2 3 1 2 3

Infectious or potentially Concentration of infectious agent(s) and Strain # or Name Toxin * Source** –Commercial or Laboratory toxin(s): (Name & Location)

*The concentration of toxins is limited by the Federal Government. Requests above those listed concentrations limits (web site) requires government approval. **If the source of your biohazard agent is a non-commercial laboratory in the United States, you must contact Office of Technology Innovation and Commercialization at ext. 7221 to obtain and sign a Material Transfer Agreement Form, MTA, for approval to be granted. Attach a copy of the MTA to this application.

Are there changes in personnel? (If the answer is yes, please list the changes Ye N below.) s o Appropriate Training Taken and Documented Last revised October 28, 2013 1 Biosafety Registration Form AMENDMENT

Add Delet Last Name First Name, MI NEU ID # Biosafety Autoclave Chemical e Hygiene 1 & 2

Is medical surveillance required? Ye N s o Are there changes in laboratory procedures? (If the answer is yes, please Ye N summarize your request for the amendment either in the space below or in an s o attachment.)

PI’s Dat signature: e:

Last revised October 28, 2013 2