Application for Permit to Import Infectious Biological A

APPLICATION FOR PERMIT TO IMPORT INFECTIOUS
BIOLOGICAL AGENTS INTO THE UNITED STATES

U.S. DEPARTMENT OF
HEALTH & HUMAN SERVICES
Public Health Service

FORM APPROVED
OMB NO. 0920-0199
EXP DATE 01/31/2017

Application Number:

Guidance for completing this form is available at http://www.cdc.gov/od/eaipp/importApplication/. This form may be
submitted by mail, fax, or email attachment to the Centers for Disease Control and Prevention, Import Permit Program
Mailing Address: 1600 Clifton Road NE, Mailstop A-46, Atlanta, GA 30333. Fax: 404-471-8333.
E-mail: [email protected]. Telephone: 404-718-2077.

Permit # issued

Please submit completed form only once by either email, fax, or mail

(For Program use ONLY)

SECTION A - Person Requesting Permit in U.S. (Permittee)
1. Permittee’s Last Name

2. Permittee’s First Name

3. MI

5. Physical Address (NOT a post office box)

4. Permittee’s Organization

6. City

7. State

9. Permittee’s Telephone Number

10. Permittee’s Fax Number

11. Permittee’s Email

12. Secondary Contact’s Name

13. Secondary Contact’s Telephone Number

14. Secondary Contact’s Email

8. Zip Code

15. Will the permittee be the courier of the imported biological
agent?
Yes
No

16. Will other members of the organization
17. Check here
if you
listed above, in Section A Block 4, be
have included a Continuation
authorized to use the approved permit?
Form to list others authorized
No
Yes if Yes
to use this permit
SECTION B - Sender of Imported Infectious Biological Agent(s) or Vector(s)
1. Sender’s Last Name ( Check if same as Sec A) 2. First Name
3. MI
4. Sender’s Organization
5. Physical Address Outside of the U.S. (NOT a post office box)

6. City

7. State/Province

10. Telephone

11. Fax

12. Email

1. Method(s) of Shipment
Commercial Carrier (e.g., FedEx)
Hand-carried by (provide name of
person):_____________________

SECTION C - Shipment Information
2. Number of Shipments
3. Shipment Temperature(s)
Single Shipment
Ambient
Multiple Shipments
Frozen/Refrigerated
i. Estimated # of shipments:____

8. Country

9. Postal Code
13. Check here
if you
have included a Continuation
Form to list multiple senders

4. Anticipated U.S. Port(s) of Entry

SECTION D - Final Destination of Imported Infectious Biological Agent(s) or Vector(s)
1. Is final destination of biological agent(s) 2. Last Name of Recipient at Destination
3. First Name
or vector(s) different from address in
Section A?
Yes
No (skip to Section E)
5. Destination Organization
6. Final Destination Address (NOT a post office box)
7. City
8. State

10. Telephone

CDC Form 0.753, Revised January 2014

11. Fax

12. Email

4. MI

9. Zip Code

13. Check here
if you
have included a Continuation
Form to list multiple final
destinations
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APPLICATION FOR PERMIT TO IMPORT INFECTIOUS BIOLOGICAL AGENTS, INFECTIOUS SUBSTANCES, OR VECTORS OF
HUMAN DISEASE INTO THE UNITED STATES
FORM APPROVED (OMB NO. 0920-0199/EXP DATE 01/31/2017)

SECTION E - Description of Infectious Biological Agent(s)
1. Intended use(s) of imported agent(s)
2. Provide a detailed description of the work to be accomplished with the imported
agent(s) (Describe your work clearly & simply. Include background, purpose, objectives, methods,
Diagnostic
etc.)
Research
Clinical trials
Education
Production
Other (please describe):
4. Scientific name of
known/suspected biological
agent(s) including Genus and
species
Scientific Name

5. Strain Designation
(list “N/A” if not
applicable)
Strain Designation

7. Laboratory or Storage
(Select one or both)

6. Location
Bldg

Suite/Room

Lab

Storage

3. Check here
if you included a
Continuation Form
to list additional
agents to be
imported with this
Permit.

8. Laboratory
Safety Level
(Leave blank if
storage only)

9. Person Responsible for
Laboratory

Safety Level

Responsible Person

a.
b.
c.
d.
SECTION F - Description of Material(s) Containing the Infectious Biological Agent(s) or Vector(s) to be Imported
1. Source of material(s) being imported (Check all that apply)
2. Description of material(s) containing biological agent(s)
(Check all that apply and provide description below)
Infected or suspected infected human
Field-collected specimen
Tissues/organs
Infected or suspected infected vector (APHIS permit may be
Laboratory isolate/culture
Body parts
required)
i (please describe)
Vector
Blood/blood products
Other body fluids
Other
ii Vector viability:
live
dead
Environment (please describe):
i Provide detailed description of the material containing the biological agent:
Other (please describe):
3. Does the material contain animal products or byproducts (e.g.,
Fetal Calf Serum or Bovine Serum Albumin)?
No
Yes (APHIS Import Permit may also be required)
1. Primary Containment to be
used (Check all that apply)
None (open bench)
Class I
Class II, Type _______
Class III
Fume Hood
Other (please describe):

SECTION G - Biosafety Measures
3. Personnel Training provided (Check all
2. Personal Protective Measures to
that apply)
be used (Check all that apply)
Risk(s) associated with the imported
Gloves
biological
agent(s)
Protective Clothing
Hazardous Material Packing/Shipping
Goggles and/or Face Shield
Laboratory Standard Practices
Facemask
Hazardous Waste Handling/Disposal
Respirators:
Emergency Response Procedures
N95/100
PAPR
Type
Spill Procedures
Immunizations
Other (please describe):
Other (please describe):

5. Anticipated disposition of Infectious Biological Agent(s) (and
material containing it) when work is completed
Will be retained at address listed in SECTION A
Will be transferred to location listed in SECTION D
Will be destroyed (please complete Block 6)

________________________________________

4. Has the permittee
implemented biosafety
measures commensurate with
the hazard posed by the
infectious biological agent,
infectious substance, and/or
vector to be imported, and the
level of risk given its intended
use?
No
Yes (Plan may be
required to be submitted)

6. If Agent(s) will be destroyed, list expected method(s) of destruction
Thermal: (describe method):______________________________________
Chemical (describe chemical):_____________________________________
Irradiation (describe energy source):_________________________________
Other (please describe): _________________________________________

I hereby certify that all individuals listed in this application have the appropriate qualifications, experience and training to safely handle the agents being imported and that the information submitted in this application is
complete and accurate to the best of my knowledge and belief. I agree to comply with all conditions, restrictions and precautions that may be specified in any permit that may be issued. Additionally, I agree to comply
with all applicable regulations and guidelines that govern this transfer. I understand that failure to comply with the importation requirements may subject me to criminal penalties pursuant to 42 U.S.C. 271.
I understand that any false statement made in this application may subject me to criminal penalties pursuant to 18 U.S.C. 1001.

1. Permittee’s Signature (REQUIRED)

SECTION H - Signature of Permittee
2. Permittee’s Printed Name (Print name)

3. Date Signed (mm/dd/yyyy)

Public recording burden of this collection of information is estimated to average 20 minutes 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 Reports Clearance Officer; 1600
Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0199)
CDC Form 0.753, Revised January 2014
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