<p> QU-IBC Application for Biosafety Approval Research involving Hazardous materials</p><p>For QU-IBC Use Only: Research No.: Received on :</p><p>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.</p><p>Title of the Research Project :</p><p>Name of Funding agency :</p><p>Grant No.: External Sponsor(s) / Collaborator(s) :</p><p>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</p><p>Methodology</p><p>Details of the Research 1. Overall Design:</p><p>2. Subjects: </p><p>3. Where will the study be carried out: </p><p>4. Are laboratories equipped by safety tools?</p><p>5. What instruments will be used for sample preparation (e.g. microwave, hot plate, etc)?</p><p>6. What instruments will be used for measurements?</p><p>7. Samples to be taken: 8. Procedure: </p><p>9. Other Tests: </p><p>10 Safety Procedures a. Outline protective equipment required to minimize exposure of laboratory personnel during all procedures requiring handling or manipulation of hazardous materials:</p><p> b. Outline procedures for decontamination of work surfaces, instruments, equipment, liquid containing hazardous materials and glassware: </p><p> c. Outline disposal/decontamination procedures for contaminated sharps, contaminated solid waste, pipette tips, etc.:</p><p>10. What possible risks, discomforts, inconveniences, side effects, costs may be experienced by the researcher?</p><p>11. If this proposal also deals with Human Subjects, was IRB approval taken?</p><p>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</p><p>Hazardous materials information Material types Material status Required information Gas Flammable Liquid Gas Toxic Liquid Liquid Acid Solid Liquid Caustic Solid Liquid </p><p>Biological Solid </p><p>Inhalation Liquid Radioactive Solid </p><p>Other</p><p> information</p><p>Confidentiality How and where will the study waste/sample be stored and secured? </p><p>Will it be reused in the future? </p><p>Any other information? </p><p>Statement of the Applicant I confirm that all required letters to the “stakeholders” have been sent.</p><p>I confirm that all information given above is true and accurate.</p><p>Name : Signature of the Applicant </p><p>Address : Date: ______</p><p>Phone Nos.: Email: Fax :</p>