Document
FORM APPROVED
ICR 201507-0920-006 · OMB 0920-0576 · Object 57189001.
This document may belong to an older filing. More recent activity for OMB 0920-0576:
Document Viewer [doc]
Document Metadata
| File Type | application/msword |
|---|---|
| File Title | FORM APPROVED |
| Author | tdg9 |
| Last Modified By | Writer |
| File Modified | 2015-07-16 |
| File Created | 2026-08-30 |
| Conversion State | complete |
Extracted Text
REQUEST TO transfer SELECT AGENTS AND TOXINS (APHIS/CDC FORM 2) FORM APPROVED OMB NO. 0920-0576 0920-0213 EXP DATE XX/XX/XXXX Detailed instructions are available at http://www.selectagents.gov/form2.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 Agriculture Select Agent Services 4700 River Road Unit 2, Mailstop 22, Cubicle 1A07 Riverdale, MD 20737 FAX: (301) 734-3652 Email: [email protected] Centers for Disease Control and Prevention Division of Select Agents and Toxins 1600 Clifton Road NE, Mailstop A-46 Atlanta, GA 30329 FAX: (404) 471-8468 Email: [email protected] Submit completed form only once by either email, fax, or mail 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. APHIS Permit #: 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. Country: 20. Responsible Official (RO) or facility director: First: MI: Last: 21. RO/Facility Director Telephone #: 22. RO/Facility Director Fax #: 23. RO/Facility Director E-mail address: 24. 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. 25. Is the agent a product of a restricted experiment, as defined in section 13 of the select agent regulations? If yes, provide the description used in the Federal Select Agent Program approval letter for the restricted experiment that produced the agent. Yes No SECTION C – LIST OF SELECT AGENTS AND TOXINS REQUESTED (attach additional sheets if necessary) 26. 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. 0920-0576 OMB NO. 0920-0213 EXP DATE XX/XX/XXXX Detailed instructions are available at http://www.selectagents.gov/form2.html. Answer all items completely and type or print in ink. This form must be signed and submitted to either APHIS or CDC: Animal and Plant Health Inspection Service Agriculture Select Agent Services 4700 River Road Unit 2, Mailstop 22, Cubicle 1A07 Riverdale, MD 20737 FAX: (301) 734-3652 Email: [email protected] Centers for Disease Control and Prevention Division of Select Agents and Toxins 1600 Clifton Road NE, Mailstop A-46 Atlanta, GA 30329 FAX: (404) 471-8468 Email: [email protected] Submit completed form only once by either email, fax, or mail 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) 27. Select agents and/or toxins: 28. Characterization of agent: 29. Number of items (e.g. vial, slant, plant, etc.): 30. Form (powder/liquid/ slant): 31. Total volume or weight of item contents (e.g., mL, mg, ng): A B C D E SECTION E – RECIPIENT NOTIFICATION INFORMATION 32. Name of Individual at Recipient Entity notified of Expected Shipment: First: MI: Last: 33. Date of notification: 34. Type of notification: E-mail Fax Telephone SECTION F – SHIPPING INFORMATION 35. Name of individual who packaged shipment: First: MI: Last: 36. Number of packages shipped: 37. Shipment Date: 38. Package description (size, shape, description of packaging including number and type of inner packages): 39. Name of carrier (If hand-delivered, please provide name of individual): 40. 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 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 (Within 2 days of transfer receipt as define in Section 16 2(h) of the select agent regulations) 41. Name of individual who received shipment: First: MI: Last: 42. Transfer Did Not Occur Transfer Occurred/Date of Receipt: 43. The agents/toxins listed in Section 2 were received: Yes If no, explain discrepancy in separate attachment. 44. 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: ______________________________________ Public reporting burden: Public reporting burden of this collection of information is estimated to average 1 hour 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. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-0576).