APHIS/CDC Form 2 Request to Transfer Select Agents and Toxins

REQUEST TO transfer SELECT AGENTS AND TOXINS (APHIS/CDC FORM 2)

FORM APPROVED OMB NO. 0579-0213 OMB NO. 0920-0576 EXP DATE XX/XX/XXXX

Detailed instructions are available at http://www.selectagent.gov/TransferForm.html. Answer all items completely and type or print in ink. This request must be signed and submitted to either APHIS or CDC:

Animal and Plant Health Inspection Service Centers for Disease Control and Prevention

Agricultural Select Agent Program Division of Select Agents and Toxins

4700 River Road Unit 2, Mailstop 22, Cubicle 1A07 1600 Clifton Road NE, Mailstop A-46

Riverdale, MD 20737 Atlanta, GA 30333

FAX: 301-734-3652 FAX: 404-718-2096

E-mail: [email protected] Email: [email protected]

APHIS/CDC AUTHORIZATION NUMBER: ______________________ EXPIRATION DATE: _________________________

SECTION 1 – TO BE COMPLETED BY RECIPIENT
SECTION A – RECIPIENT INFORMATION
1. Entity name:		2. Entity registration number:
3. Address (NOT a post office address):		4. City:		5. State:	6. Zip Code:
7. Principal Investigator name First: MI: Last:		8. a. APHIS Permit #: b. US PHS#:
9. Responsible Official (RO) name First: MI: Last:		10. RO Telephone #:
11. RO FAX #:		12. RO E-mail address:
SECTION B – SENDER INFORMATION
13. Entity name:		14. Entity registration number: ______________________________ Clinical/diagnostic laboratory Other: _______________________________________
15. Address (NOT a post office address):		16. City:	17. State:		18. Zip Code:
19. Responsible Official (RO) or facility director First: MI: Last:		20. RO/Facility Director Telephone #:
21. RO/Facility Director FAX #:		22. RO/Facility Director E-mail address:
23. This transfer request is for a select agent or toxin that was identified in a clinical or diagnostic sample:  Yes  No If yes, please ensure that an APHIS/CDC Form 4 “Report of the Identification of a Select Agent or Toxin” is submitted to APHIS or CDC within 7 calendar days.
SECTION C – LIST OF SELECT AGENTS AND TOXINS REQUESTED (attach additional sheets if necessary)
24. Select agents and/or toxins to be transferred:
A
B
C
D
E

I hereby certify that the information contained in Section 1 on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false statement on any part of this form, or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR 331, 9 CFR 121, and 42 CFR 73 may result in civil or criminal penalties, including imprisonment.

Signature of Responsible Official: _________________________________________________ Title: ____________________________________

Typed or printed name of Responsible Official: _______________________________________ Date: ____________________________________

REQUEST TO transfer SELECT AGENTS AND TOXINS (APHIS/CDC FORM 2)

FORM APPROVED OMB NO. 0579-0213 OMB NO. 0920-0576 EXP DATE XX/XX/XXXX

Read all instructions carefully before completing the report. This report must be signed and submitted to either APHIS or CDC:

Animal and Plant Health Inspection Service Centers for Disease Control and Prevention

Agricultural Select Agent Program Division of Select Agents and Toxins

4700 River Road Unit 2, Mailstop 22, Cubicle 1A07 1600 Clifton Road NE, Mailstop A-46

Riverdale, MD 20737 Atlanta, GA 30333

FAX: 301-734-3652 FAX: 404-718-2096

E-mail: [email protected] Email: [email protected]

APHIS/CDC AUTHORIZATION NUMBER: ______________________ EXPIRATION DATE: _________________________

SECTION 2 – TO BE COMPLETED BY SENDER
SECTION D – LIST OF SELECT AGENTS AND TOXINS SHIPPED (attach additional sheets if necessary)
	25. Select agents and/or toxins:	26. Characterization of agent:			27. Number of items (e.g. vial, slant, plant, etc.):	28. Form (powder/liquid/ slant):		29. Total volume or weight of item contents (e.g., mL, mg, ng):
A
B
C
D
E
SECTION E – RECIPIENT NOTIFICATION INFORMATION
30. Name of Individual at Recipient Entity notified of Expected Shipment: First: MI: Last:			31. Date of notification:				32. Type of notification:  E-mail  Fax  Telephone
SECTION F – SHIPPING INFORMATION
33. Name of individual who packaged shipment: First: MI: Last:			34. Number of packages shipped:				35. Shipment Date:
36. Package description (size, shape, description of packaging including number and type of inner packages):
37. Name of carrier (If hand-delivered, please provide name of individual):				38. Airway bill number/bill of lading number/tracking number:

I hereby certify that the select agents and/or toxins were packaged, labeled, and shipped in accordance with all federal and international regulations and information contained on in Section 2 of this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false statement on any part of this form, or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR 331, 9 CFR 121, and 42 CFR 73 may result in civil or criminal penalties, including imprisonment.

Signature of Sender: ____________________________________________________________ Title: ________________________________________________

Typed or printed name of Sender: ___________________________________________________________ Date: _____________________________________

SECTION 3 – TO BE COMPLETED BY RECIPIENT
39. Name of individual who received shipment: First: MI: Last:	40.  Transfer Did Not Occur  Transfer Occurred/Date of Receipt:
41. The agents/toxins listed in Section 2 were received:  Yes  If no, explain discrepancy in separate attachment.	42. Shipment was packaged, labeled, and shipped in accordance with regulations:  Yes  If no, explain discrepancy in separate attachment.

I hereby certify that the information contained in Section 3 on this form is true and correct to the best of my knowledge. I understand that if I knowingly provide a false statement on any part of this form, or its attachments, I may be subject to criminal fines and/or imprisonment. I further understand that violations of 7 CFR 331, 9 CFR 121, and 42 CFR 73 may result in civil or criminal penalties, including imprisonment.

Signature of Responsible Official: __________________________________________________ Title: _______________________________________________

Typed or printed name of Responsible Official: _________________________________________________ Date: ________________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0213 The time required to complete this information collection is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.