Application for Biosafety Approval

QU-IBC Application for Biosafety Approval Research involving Hazardous materials

For QU-IBC Use Only: Research No.: Received on :

Note to Applicants: Please provide the details requested below and put N/A where the information is not relevant or not required on your part.

Title of the Research Project :

Name of Funding agency :

Grant No.: External Sponsor(s) / Collaborator(s) :

Details of All Investigators Signatures are mandatory for those affiliated with QU Faculty: Post/Docs. Name, Position & Student : Training related to Signatures Department Graduate / Research (QU staff only) Undergraduat e Lay Summary : (Include Objectives & Methodology) (Max 300 words) Objectives

Methodology

Details of the Research 1. Overall Design:

2. Subjects:

3. Where will the study be carried out:

4. Are laboratories equipped by safety tools?

5. What instruments will be used for sample preparation (e.g. microwave, hot plate, etc)?

6. What instruments will be used for measurements?

7. Samples to be taken: 8. Procedure:

9. Other Tests:

10 Safety Procedures a. Outline protective equipment required to minimize exposure of laboratory personnel during all procedures requiring handling or manipulation of hazardous materials:

b. Outline procedures for decontamination of work surfaces, instruments, equipment, liquid containing hazardous materials and glassware:

c. Outline disposal/decontamination procedures for contaminated sharps, contaminated solid waste, pipette tips, etc.:

10. What possible risks, discomforts, inconveniences, side effects, costs may be experienced by the researcher?

11. If this proposal also deals with Human Subjects, was IRB approval taken?

Yes No Pending N/A 13. If this proposal also deals with Animal Subjects, was IACUC approval taken? Yes No Pending N/A 15. Is the approval of a Radiation Safety Officer sought/needed? Yes No Pending N/A

Hazardous materials information Material types Material status Required information Gas Flammable Liquid Gas Toxic Liquid Liquid Acid Solid Liquid Caustic Solid Liquid

Biological Solid

Inhalation Liquid Radioactive Solid

information

Confidentiality How and where will the study waste/sample be stored and secured?

Will it be reused in the future?

Any other information?

Statement of the Applicant I confirm that all required letters to the “stakeholders” have been sent.

I confirm that all information given above is true and accurate.

Name : Signature of the Applicant

Address : Date: ______

Phone Nos.: Email: Fax :