Tissue transfer form | NAU Research

Provide the following information

NAU Principal Investigator(Required)

First Last

Department(Required)

Campus phone number(Required)

Campus email(Required)

Protocol title/number(Required)

Tissue source

Name(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 requested

Species(Required)

Tissue type(Required)

Quantity(Required)

Frequency of transfer(Required)

Method of transfer(Required)

Hazard potential

Has the tissue been screened for human/animal pathogens?(Required)

Yes

Will tissue be treated (preserved, digested, etc.) prior to transfer to NAU?(Required)

Yes

If yes, provide a description of how tissue is treated:

Will tissue be transferred into live animals?(Required)

Yes

If yes, provide protocol information describing procedure:

Was the animal intentionally or otherwise suspected to be infected?(Required)

Yes

If yes, provide information on the organism/disease:

Are there any additional hazards associated with this tissue?(Required)

Yes

If yes, provide description of hazard:

Tissue Use

Briefly describe how tissue will be used:(Required)

Describe method of tissue disposal:(Required)

Personnel Training

Describe 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)

Initial

Tissue proposed for use is not from an endangered species.(Required)

Initial

Tissue shipment does not violate the Convention of International Trade of Endangered Species (CITES).(Required)

Initial

Tissue proposed for use and its shipment does not violate the Migratory Bird Act.(Required)

Initial

By 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)

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Provide the following information

Tissue source

Tissue requested

Hazard potential

Tissue Use

Personnel Training