Reporting The Identification Of A Select Agent Or Toxin

REPORTING THE IDENTIFICATION OF A SELECT AGENT OR
TOXIN: PROFICIENCY TESTING REPORT
(APHIS/CDC FORM 4B)

FORM APPROVED
OMB NO. 0579-0213
OMB NO. 0920-0576
EXP DATE 12/31/2018

INSTRUCTIONS
Detailed instructions are available at http://www.selectagents.gov/form4.html. Answer all items completely and type or print in
ink. This report must be signed and submitted to either APHIS or CDC:
Animal and Plant Health Inspection Service
Agriculture Select Agent Program
4700 River Road Unit 2, Mailstop 22, Cubicle 1A07
Riverdale, MD 20737
FAX: (301) 734-3652
E-mail: [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) 471-8469
E-mail: [email protected]

Accession Number:

(For Program Use ONLY)

Submit completed form only once by either e-mail, fax, or mail
SECTION A – INFORMATION FOR LABORATORY THAT RECEIVED PROFICIENCY TESTING SAMPLE(S)
1. Name of individual completing the form:
2. E-mail address:
3. Telephone #:
First:
MI:
Last:
 Registered Entity (APHIS or CDC Registration #: ______________________)
 Clinical or Diagnostic Laboratory [non-registered entity (NRE)]
(NRE # (provided by APHIS or CDC): ____________________________)
6. Responsible Official or Laboratory Supervisor name:
First:
MI:
Last:

5. Entity name:

8. Telephone #:

11 .City:

4.

9. Fax #:

10. E-mail address:

7. Address (NOT a post office address):
12. State:

13. Zip Code:

14. Sponsor/entity that you received select agent or toxin from:
Entity name:_________________________________________________________
Registration #:_________________________________________
Entity address:___________________________________________________________________
Telephone #:______________________________ E-mail:______________________________
SECTION B – SELECT AGENTS AND TOXINS IDENTIFIED FROM PROFICIENCY TESTING
1. Select Agent or Toxin Identified
2. Date obtained from sponsor
3. Date identified

4. Dispositions of select agents or toxins (complete all that apply):
 Transferred (Provide entity name and date of transfer. Entity: __________________________________________ Date:_____________________)
 Destroyed (Provide destruction method and date. Method: __________________________ Date:_____________________)
 Retained (Provide name of person retaining sample. Name:_____________________________________________________)
5. Were any of the samples containing a select agent or toxin, listed in the table above, and handled outside of primary containment which may have led to an
unintentional release and/or exposure to the select agent or toxin?
 No  Yes (If Yes, you are required under 7 CFR Part 331.19, 9 CFR Part 121.19, and 42 CFR Part 73.19 to complete and submit an APHIS/CDC Form 3)
I hereby certify that the information contained 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, or 42 CFR
73 may result in civil or criminal penalties, including imprisonment.
Signature of Responsible Official/Laboratory Supervisor:_________________________________________________

Date Signed: _______________________

Public reporting burden: Public reporting burden of providing this 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 D74, Atlanta, Georgia 30329; ATTN: PRA (0920-0576)

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