Form 0920-0199 Appliation for Permit to Import Infectious Biological Ag

8/23/2018

Agents Form - CDC_IPP2

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

SECTION A

SECTION B

SECTION C

SECTION D

SECTION E

SECTION F

SECTION G

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Section A
PERSON REQUESTING PERMIT IN U.S.(PERMITTEE)
Primary Permittee Request

1. Primary Permittee's Last Name 

2. Primary Permittee’s First Name 

3. Primary Permittee’s Organization 

4. Physical Address (NOT a post office box) 

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5. City 

6. State 

-- Select an option--

7. Zip Code 

_____-____

8. Permittee’s Telephone Number 

(___)___-____ext._____

9. Permittee’s Email 

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

11. Secondary Contact’s Name

12. Secondary Contact’s Telephone Number

(___)___-____ext._____

13. Secondary Contact’s Email

14. Institutional Biosafety Officer’s Name

15. Institutional Biosafety Officer’s Telephone Number

(___)___-____ext._____
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16. Institutional Biosafety Officer’s Email

Authorized User(s)

First Name

Last Name

Organization

 Add From Template

 Add User

Section B
SENDER OF IMPORTED INFECTIOUS BIOLOGICAL AGENT(S) OR VECTOR(S)
Sender(s)

First Name

Last Name

Organization

Country

 Add From Template
https://eipp.cdc.gov/Agents

 Add Sender
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Section C
SHIPMENT INFORMATION
1. Method(s) of Shipment 

Must choose at least one of the below
Commercial Carrier (e.g., FedEx)
Hand-carried by individuals listed in Section A

2. Estimated Number of Shipments 

________

Section D
DESCRIPTION OF INFECTIOUS BIOLOGICAL AGENT(S) AND PERMITTEE'S
LABORATORY

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1. Intended use(s) of imported agent(s): 
Must choose at least one of the below
Diagnostic
Research
Clinical trials
Education
Production
Other

2. Provide a detailed description of the work to be accomplished with the imported agent(s) (Describe your work clearly &
concisely, include background, purpose, objectives, methods, etc.)


3. Will the agent(s) be propagated or cultured? 
Yes
No

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4. Will the agent(s) be used to inoculate animals or arthropods? 
Yes
No

Infectious Biological Agents

Scientific Name

Strain

Building Location

Room Location

Lab

Lab Safety Level

 Add From Template

Storage

Add Infectious Biological Agent

Section E
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)
Must choose at least one of the below
Infected or suspected infected human
Infected or suspected infected vector
Environment
Recombinant/synthetic (please describe)
Other
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2. Description of material(s) containing biological agent(s) 
Must choose at least one of the below
Field-collected specimen
Laboratory derived isolate/culture
Blood/blood products
Other bodily fluids
Tissues
Organs/Body parts
Vector
Other

Provide a detailed description of the material containing the biological agent

Section F
BIOSAFETY MEASURES
1. Primary Containment to be used (Check all that apply) 
None (open bench)
Class I
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Class II
Class III
Fume Hood
Negative pressure ventilated enclosure with HEPA filtration
Other

2. Personal Protective Measures to be used (Check all that apply) 
Gloves
Protective Clothing
Goggles
Face Shield
Facemask
N95 or N100 Respirator
Powered Air Purifying Respirator (PAPR)
Immunizations
Other

3. Personnel Training provided (Check all that apply) 
Risk(s) associated with the imported biological agent(s)
Hazardous Material Packing/Shipping
Laboratory Standard Practices
Hazardous Waste Handling/Disposal
Emergency Response Procedures
Spill Procedures
Other

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? (Submission of a biosafety plan
may be required for permit approval) 
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Yes
No

5. Anticipated disposition of Infectious Biological Agent(s) (and material containing it) when work is completed 
Must choose at least one of the below
Will be retained at address listed in SECTION A
Will be transferred to location listed in SECTION G
Will be destroyed

Section G
FINAL DESTINATION(S) OF IMPORTED BIOLOGICAL AGENT(S) OR VECTOR(S)
1. Will the permittee transfer the imported materials to locations not listed in Section D above? 
Yes
No

 Signature

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Certification: 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.

Signature of Respondent:

Date:
08/23/2018

FORM APPROVED
OMB NO. 0920-0199
EXP DATE 04/30/2021
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).

 Save Draft

https://eipp.cdc.gov/Agents

 Submit to IPP

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DSAT Contact Information

Centers for Disease Control and Prevention
Import Permit Program
1600 Clifton Road, NE, Mailstop A-46
Atlanta, GA 30329
Telephone: 404-718-2000
Email: [email protected]

Help and Support

eFSAP Customer Support Request Form (https://www.cdc.gov/phpr/ipp/support.htm)
Telephone: (833) 271-8310
Email: [email protected]

© 2017 - CDC - Import Permit Program

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