LABORATORY SAFETY DATASHEET

______ new or competing renewal	______ revision or non-competing renewal (only indicate new changes)

Principal Investigator (degree):				PI’s Department:

Check one: ______ BU Medical Campus (BUMC)		______ Boston Medical Center (BMC)

PI’s Phone Number:					PI’s e-mail address:

Laboratory location(s) where work will be performed (indicate biosafety level if multiple labs are to be used):

Laboratory phone number(s):

Name of Chemical Hygiene Officer (CHO):
CHO’s e-mail address:
Emergency contact information (name and phone number, 24/7):

Biosafety level: _____ BL1    _____BL2    _____BL2+    _____BL3    (can check more than one)

rDNA:			_____yes    _____no	rDNA approval number(s):

Human Subjects:		_____yes    _____no  	IRB approval number(s):

Laboratory animals:	_____yes    _____no	IACUC approval number(s):

Use of human blood, tissues, cells, or blood products:	  _____yes	_____no

Are laboratory workers vaccinated against hepatitis B?  _____yes	_____no

Viruses:  _____yes    _____no	list:

Bacteria:  _____yes    _____no	list:

Other microbes or non-vertebrate organisms:	  _____yes	_____no 	list:

Microbial toxins (natural, synthetic, derivatives):  _____yes         _____no           	list:

Radioisotopes: _____none    _____32P    _____35S    _____3H    _____14C    _____125I    _____51Cr

Other radioisotopes:

Are research materials provided by (circle one) an outside investigator, institution, or company (i.e. not commercially available research materials)?  _____yes    _____no

Is there a Materials Transfer Agreement? _____NA, _____on file, _____under negotiation/pending at either _____BUMC, or _____BMC

Signature of PI: ________________________________	Date: ____________