ON THIS PAGE Request info ON THIS PAGERequest info HOW CAN WE HELP? 928-523-1330 Kathleen.Freel@nau.edu NAU>Research>Institutional Animal Care and Use Committee (IACUC)>Tissue transfer formTissue transfer form Provide the following informationNAU Principal Investigator(Required) First Last Department(Required) Campus phone number(Required)Campus email(Required) Protocol title/number(Required) Tissue sourceName(Required) First Last Phone number(Required)Email(Required) Institution(Required) Protocol number/title under which tissue was collected(Required) OLAW Welfare Assurance Number(Required) Tissue requestedSpecies(Required) Tissue type(Required) Quantity(Required) Frequency of transfer(Required) Method of transfer(Required) Hazard potentialHas the tissue been screened for human/animal pathogens?(Required) Yes No Will tissue be treated (preserved, digested, etc.) prior to transfer to NAU?(Required) Yes No If yes, provide a description of how tissue is treated: Will tissue be transferred into live animals?(Required) Yes No If yes, provide protocol information describing procedure: Was the animal intentionally or otherwise suspected to be infected?(Required) Yes No If yes, provide information on the organism/disease: Are there any additional hazards associated with this tissue?(Required) Yes No If yes, provide description of hazard: Tissue UseBriefly describe how tissue will be used:(Required)Describe method of tissue disposal:(Required)Personnel TrainingDescribe personnel training for procedures with this tissue:(Required)It is the responsibility of the PI/Research Leader to have all necessary permits from regulatory agencies such as CDC, FDA, Fish and Wildlife, etc., in place prior to receipt of tissue. Applicants are encouraged to contact the ORC for guidance. Must be conducted in accordance with federal shipping and importation guidelines. The PI is responsible for being in compliance with all regulations regarding shipping tissues that may have been exposed to animal diseases or present a zoonotic risk to humans. The NAU BSO can provide Standard Operating Procedures (SOPs) for sample handling and transport and detailed information on USDA, CDC, APHIS, and PHS regulations. Hazardous sample shipping and receiving courses are available and must be completed before tissue transfer to NAU. Indicate the building and room number where the tissue will be kept. Describe safety and containment measures taken to prevent the spread of potentially infectious diseases contained in the tissues. Describe security measures taken to prevent theft/loss of tissue. Facility may be inspected prior to tissue delivery. Signatures: PI must initial the following, verifying that each statement is true:This description is accurate and complete. All personnel are adequately trained to perform these procedures and are enrolled in the occupational health program. Safety practices will be adhered to. All vertebrate animal tissues will be acquired through lawful means, judiciously used and disposed of appropriately. I have read and understand the guidelines associated with this application.(Required) InitialTissue proposed for use is not from an endangered species.(Required) InitialTissue shipment does not violate the Convention of International Trade of Endangered Species (CITES).(Required) InitialTissue proposed for use and its shipment does not violate the Migratory Bird Act.(Required) InitialBy checking the box, I certify that to the best of my knowledge, the information included herein is accurate and complete.(Required) Yes, I agree with this statement. Date(Required) MM slash DD slash YYYY