Form APHIS/CDC FORM 2 APHIS/CDC FORM 2 REQUEST FOR TRANSFER SELECT AGENTS AND TOXINS

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

FORM APPROVED OMB NO. 0579-0213

OMB NO. 0920-0578 EXP DATE XX/XX/XXXX

Detailed instructions are available at http://www.selectagents.gov/form2.html. This request must be submitted to either AgSAS or DSAT.

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

E-mail: [email protected]

Centers for Disease Control and Prevention

Division of Select Agents and Toxins

1600 Clifton Road NE, Mailstop H21-7 Atlanta, GA 30329FAX: (404) 471-8468

E-mail: [email protected]

Submit completed form only once by either eFSAP, e-mail, fax, or mail

SECTION 1 – TO BE COMPLETED BY RECIPIENT
SECTION A – RECIPIENT INFORMATION
1. Entity name:		2. Entity registration number:		Transfer extension requested (only for approved transfers):  Yes  No
3. Principal Investigator name: First: MI: Last:		4. PPQ Permit # (if applicable):
SECTION B – SENDER INFORMATION
5. Entity name:		6. Address (NOT a post office address):
7. Responsible Official (RO) or Laboratory Supervisor: First: Last:		8. City:	9. State:		10. Zip code:	11. Country:
12. RO/Laboratory Supervisor telephone #:		13. RO/Laboratory Supervisor e-mail address:
13. This transfer request is for a select agent or toxin that was identified in a clinical or diagnostic sample:  Yes  No If yes, provide the APHIS/CDC Form 4 clinical ID#:
14. 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)
15. Select agents and/or toxins to be transferred (for toxins, please include the amount):
A
B
C
D
E
16. Transfer is cancelled:  Yes  No
17. Name of carrier and DOT registration number (If hand-delivered, please provide name of individual):

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 Part 331, 9 CFR Part 121, or 42 CFR Part 73 may result in civil or criminal penalties, including imprisonment.

Signature of Responsible Official: Typed or printed name of Responsible Official:

Title: Date:

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

FORM APPROVED OMB NO. 0579-0213

OMB NO. 0920-0578 EXP DATE Xx/XX/XXXX

Detailed instructions are available at http://www.selectagents.gov/form2.html. This form must be submitted to either AgSAS or DSAT:

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

E-mail: [email protected]

Centers for Disease Control and Prevention Division of Select Agents and Toxins

1600 Clifton Road NE, Mailstop H21-7 Atlanta, GA 30329

FAX: (404) 471-8468

E-mail: [email protected]

Submit completed form only once by either eFSAP, e-mail, fax, or mail

SECTION 2 – TO BE COMPLETED BY SENDER
SECTION D – LIST OF SELECT AGENTS AND TOXINS SHIPPED (attach additional sheets if necessary)
	18. Select agents and/or toxins:	19. Characterization of agent:	20. Number of items (e.g., vial, slant, plant, etc.):		21. Form (powder/liquid/ slant):	22. Total volume or weight of item contents (e.g., mL, mg, ng):
A
B
C
D
E
23. Transfer is cancelled:  Yes  No
SECTION E – RECIPIENT NOTIFICATION INFORMATION
24. Name of individual at recipient entity notified of expected shipment: First: MI: Last:		25. Date of notification:		26. Type of notification:  E-mail  Fax Telephone   
SECTION F – SHIPPING INFORMATION
27. Name of individual who packaged shipment: First: MI: Last:		28. Number of packages shipped:			29. Shipment date:
30. Package description (size, shape, description of packaging including number and type of inner packages):
31. 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 Part 331, 9 CFR Part 121, or 42 CFR Part 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 receipt of shipment)
30. Name of individual who received shipment: First: Last:	31: Date of receipt:
32. The agents/toxins listed in Section 2 were received:  Yes  No If no, explain discrepancy in separate attachment.
33. Shipment was packaged, labeled, and shipped in accordance with regulations:  Yes  No 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 Part 331, 9 CFR Part 121, or 42 CFR Part 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 1.5 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. 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).