APHIS/CDC Form 2 Request to Transfer Select Agents and Toxins

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

FORM APPROVED
OMB NO. 0920-0576
EXP DATE: 01/31/2024

Detailed instructions are available at http://www.selectagents.gov/form2.html. This request must be submitted to either
DASAT or DSAT.
Animal and Plant Health Inspection Service
Division of Agricultural Select Agents and Toxins
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 H21-4
Atlanta, GA 30329
FAX: (404) 471-8468
E-mail: [email protected]

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

SECTION 1 – TO BE COMPLETED BY RECIPIENT
SECTION A – RECIPIENT INFORMATION
2. Principal Investigator name:
First:
MI:

1. Entity name:

Last:

:
SECTION B – SENDER INFORMATION
3. Entity name:

4. Address (NOT a post office address):

5. Responsible Official (RO) or Laboratory Supervisor:
First:
Last:

6. City:

10. RO/Laboratory Supervisor telephone #:

11. RO/Laboratory Supervisor e-mail address:

7. State:

8. Zip code:

9. Country:

{Select}

12. 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#:
13. Is the agent a product of a restricted experiment, as defined in section 14 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)
14. Select agents and/or toxins to be transferred (for toxins, please include the total amount):
A

{Select}

B

{Select}

C

{Select}

D

{Select}

E

{Select}

15. Transfer is canceled: Yes

No

16. 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:

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
EXP DATE: 01/31/2024

Detailed instructions are available at http://www.selectagents.gov/form2.html. This form must be submitted to either DASAT
or DSAT:
Animal and Plant Health Inspection Service
Division of Agricultural Select Agents and Toxins
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 H21-4
Atlanta, GA 30329
FAX: (404) 471-8468
E-mail: [email protected]

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

SECTION 2 – TO BE COMPLETED BY SENDER
SECTION D – LIST OF SELECT AGENTS AND TOXINS SHIPPED (attach additional sheets if necessary)
17. Select agents and/or toxins:

18. Characterization
of agent:

A {Select}
B {Select}
C {Select}

19. Number of
items (e.g.,
vial, slant,
plant, etc.):

D {Select}
E {Select}

20. Form
(powder/liquid/
slant):

21. Total volume or
weight of item contents
(e.g., mL, mg, ng):

{Select}

{Select}

{Select}
{Select}

{Select}

{Select}

{Select}

{Select}

{Select}

{Select}

SECTION E – RECIPIENT NOTIFICATION INFORMATION
22. Name of individual at recipient entity notified of expected shipment:
First:
MI:
Last:

24. Type of Notification
 E-mail
 Fax


23. Date of notification:

SECTION F – SHIPPING INFORMATION
25. Name of individual who packaged shipment:
26. Number of packages shipped:
First:
MI:
Last:
28. Package description (size, shape, description of packaging including number and type of inner packages):

 Telephone

27. Shipment date:

29. Airway bill number/bill of lading number/tracking number:
I hereby acknowledge that regardless of the carrier used to execute an approved transfer of select agents and/or toxins, it is the responsibility of the sender to ensure the transfer/shipment is
in compliance with applicable federal, state and local requirements for packaging and transportation, such as the U.S. Department of Transportation (DOT) Hazardous Materials Regulations
for the transport of Infectious Substances. In addition, I acknowledge that for plant pathogens, interstate and certain intrastate movements will require a valid USDA/APHIS permit. I
understand that knowingly providing a false statement on any part of this form or violating the federal select agent regulations (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:
Typed or printed name of Sender:

Title:

_
Date:

_

SECTION 3 – TO BE COMPLETED BY RECIPIENT
(Within 2 days of receipt of shipment)

30. Name of individual who received shipment:
31. Date of receipt:
First:
Last:
 No
32. The agents/toxins listed in Section 2 were received:  Yes
If no, explain discrepancy in separateattachment.
 No
33. Shipment was packaged, labeled, and shipped in accordance with regulations:  Yes
If no, explain discrepancy in separateattachment.

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:
Typed or printed name of Responsible Official:

Title:

_
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).