Verification of Biological Toxin Inactivation

O n e C a r d A c c e s s A u t h o r i z a t i o n F o r m M c G a v r a n G r e e n b e r g 3 2 2 1 & M i c h a e l H o o k e r R e s e a r c h C e n t e r 3 1 0 4

Department of Environment, Health & Safety, University of North Carolina at Chapel Hill

To activate your one card for access to MG 3221 and MHRC 3104, complete the top section of this form, sign the bottom and obtain the Principal Investigators signature. The form should then be sent to:

UNC Department of Environment, Health & Safety http://ehs.unc.edu 1120 Estes Drive Extension, CB# 1650 919-962-5507 Chapel Hill, NC 27599-1650 Fax: 919-962-0227

Employees will only be granted access if they meet the lab entry requirements, including training, and with approval of the laboratory Principal Investigator and the UNC-Chapel Hill Biological Safety Officer. The PI and BSO may cancel card access privileges at any time. Card access privileges will be cancelled if employee is noncompliant with lab procedures or security requirements.

Name of Cardholder: PID#:

Department: Phone#:

Campus Address: Email address:

Employee Signature: Date:

I certify that I meet the entry requirements for this laboratory. I understand that the PI and BSO may cancel my card access privileges at any time and that my card access privileges will be cancelled if I am noncompliant with lab procedures or security requirements. Principal Investigator Signature: Date:

I certify that this employee meets the entry requirements for this laboratory. This employee’s card access privileges will be cancelled if he/she is noncompliant with lab procedures or security requirements.

UNC-Chapel Hill Biological Safety Officer Signature: Date:

EHS Use Only:

If EHS approves access, the form will be provided to Brent Wishart, Facilities Coordinator, School of Public Health, 137 Rosenau Hall and access will be granted. If you have any questions, please contact EHS.

Date Access Cancelled:

May 2011