University of Texas Health Science Center at San …

1 University of Texas Health Science Center at San Antonio Revision date: December 06, 2010 Flow cytometry form for unfixed biohazard and/or toxic Materials UTHSCSA Flow cytometry Facility is a multi-user facility where many different samples from various sources that contain unknown animal and human pathogens are analyzed or sorted. The safety of the staff and users of the facility is the ultimate concern. Therefore, information about the samples sources and infections agents is critical for effective safety risk assessment. This form is NOT applicable to samples that are fixed for flow cytometry analysis. Please contact the Flow Core staff if you need help differentiating between cell sorting and cell analysis. This form must be filled out completely and signed by the principal investigator prior to bring live samples into the core. Appropriate biosafety and/or chemical approval prior to use of the facility is required.

2 The process of high-speed sorting produces aerosols can constitute a Health hazard to facility personnel and users. For this reason, sample restrictions listed below will be followed: o No samples containing radioactivity will be sorted o No samples containing Risk Group 3/BSL-3 (or higher) will be allowed in the Flow cytometry core. 1. Give a brief description of the cells/cell line or other biohazardous agents that will be brought into the Flow cytometry Core. _____ 2. Sample Biosafety level: BSL1 BSL2 3. Are these samples of human origin? Yes No If yes, were the donors screened for blood borne pathogens? Yes No 4. Are these samples of primate origin? Yes No If samples are of primate origin, which primate? _____ 5. Were the cells transformed using a virus or viral vector such as EBV, HTLV-1, herpes, adenovirus, retrovirus, lentivirus, etc?

3 Yes No. If yes, please list virus/viral vector: _____ Has the preparation been shown to be free of replication-competent virus? Yes No Does the preparation contain an oncogene? Yes No 6. Does the PI have Environmental Health & Safety (EH&S) approval to possess and use the cells or biohazardous agent? Yes No 7. Do the samples contain chemical carcinogens or other toxic agents? Yes No If yes, what agents? _____ If yes, please bring a copy of your chemical safety approval for the core s records. 8. Date(s) needed: _____ All requests for sorts involving Risk Group 2/BSL-2 level organisms and/or infected samples require a current Institutional Biosafety Committee approval on file in the EH&S. Please supply a copy of your approval letter when submitting this form . All sorts containing carcinogens or other chemical toxins require a current Institutional Chemical Safety Committee approval.

4 If the PI does not have the approval letter for the use of the cells and/or pathogen, and/or chemicals, the sort time will be canceled. Prior to the sort of a risk Group 2 infectious agent, the PI is required to meet with the Flow cytometry director to discuss the risks of the agent (including signs and symptoms). Principal Investigator _____ Principal Investigator Signature: _____ Date:_____