FSU College of Medicine - Confocal Facility New User Registration

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Confocal Facility
New User Registration

This form is for all users of the Confocal Facility.
Items marked with a * must be completed.

Researcher Information
*Project Title:
*Principal Investigator:
*PI's Institution:
*PI Email:
*Investigator Name:
*Investigator Email:
*Investigator Phone:
Potential Hazard
Note: The PI must ensure all members involved in the project will be informed of the potential hazard associated with the project.
*Does the sample have any potentially harmful effects to humans, animals, plants, or the environment? Yes No
If yes, check all that apply: Samples contain chemical (complete the chemical section) Samples contain radioactive material (complete the radioactive material section) Samples contain infectious material (complete the infectious material section) Samples contain Select Agent, see attached list of Select Agents (complete the Select Agents section) Samples contain biological material (complete the biological material section) Sample is an animal or part of an animal (complete the animal section) Sample is from a human source (complete the human section) Sample present other type of potential hazard (complete the other section)
Chemical Section
Name of chemical (list CAS number if known):
Amount of chemical in the sample:
Check all that apply:	Chemical is toxic Chemical is reactive Chemical is flammable Chemical is corrosive Chemical is explosive
Radioactive materials section
Note: Contact the Radiation Safety Office at 644-8802 or 644-8801 prior to use.
Radioisotope:
Activity amount:
Infectious material section
Note: Contact the Biological Safety Office at 644-5374 or 644 9117 prior to use.
Name of infectious material:
Amount of infectious material:
What disease does the infectious material cause?
Select Agent materials section
Note: Contact the Biological Safety Office at 644-5374 or 644-9117 prior to use.
Name of Select Agent:
Amount of Select Agent:
Should the Select Agent be used at biosafety level 2 or above?	Yes No
If yes, list biosafety level:
Biological materials section
Note: For all biological material that is biohazardous, contact the Biological Safety Office at 644-5374 or 644-9117 prior to use.
Name of biological material:
Amount of biological material:
Is the biological material biohazardous?	Yes No
If yes, should the biological material be used at a biosafety level 2 or above?	Yes No
If yes, list biosafety level:
List potentially harmful effects:
Animal section
Note: For whole animal use, contact the Florida State University Animal Care and Use Committee at 644-2873 prior to use.
Type of animal sample:
Is the animal a whole animal? If yes continue. If no, go to the Animal part section.	Yes No
Has the use of the animal been approved by the Florida State University Animal Care and Use Committee (ACUC)? If no, approval must be obtained by the ACUC	Yes No
ACUC Protocol Number:
Animal part section
Type of animal part:
List potentially harmful effects:
Human section
Note: For human sample source use, contact the Florida State University Human Subject Committee at 644-8633 prior to use.
Type of human sample:
Does the human sample require approval by the Florida State University Human Subject Committee (HSC) or the PIs institutional HSC?	Yes No
HSC Application number:
List potentially harmful effects:
Other section
Other potential hazards:
List potentially harmful effects:
Department of Health and Human Services and the United State Department of Agriculture Select Agents and Toxins list
Crimean-Congo haemorrhagic fever virus Coccidioides posadasii Ebola viruses Cercopithecine herpesvirus 1 (Herpes B virus) Lassa fever virus	Marburg virus Monkeypox virus Rickettsia prowazekii Rickettsia rickettsii
South American Haemorrhagic fever viruses
Junin Machupo Sabia Flexal Guanarito
Tick-borne encephalitis complex (flavi) viruses
Central European tick-borne encephalitis Far Eastern tick-borne encephalitis Russian spring and summer encephalitis Kyasanur forest disease Omsk hemorrhagic fever
Variola major virus (Smallpox virus) Variola minor virus (Alastrim) Yersinia pestis Abrin Conotoxins Diacetoxyscirpenol Ricin Saxitoxin Shiga-like ribosome inactivating proteins Tetrodotoxin Bacillus anthracis Brucella abortus Brucella melitensis Brucella suis Burkholderia mallei (formerly Pseudomonas mallei) Burkholderia pseudomallei (formerly Pseudomonas pseudomallei) Botulinum neurotoxin producing species of Clostridium Coccidioides immitis Coxiella burnetii Eastern equine encephalitis virus Hendra virus Francisella tularensis Nipah Virus Rift Valley fever virus Venezuelan Equine Encephalitis virus Botulinum toxins	Clostridium perfringens epsilon toxin Shigatoxin Staphylococcal enterotoxins T-2 toxin Akabane virus African swine fever virus African horse sickness virus Avian influenza virus (highly pathogenic) Blue tongue virus (Exotic) Bovine spongiform encephalopathy agent Camel pox virus Classical swine fever virus Cowdria ruminantium (Heartwater) Foot and mouth disease virus Goat pox virus Lumpy skin disease virus Japanese encephalitis virus Malignant catarrhal fever virus (Exotic) Menangle virus Mycoplasma capricolum/ (M.F38/M. mycoides capri) Mycoplasma mycoides mycoides Newcastle disease virus (VVND) Peste Des Petits Ruminants virus Rinderpest virus Sheep pox virus Swine vesicular disease virus Vesicular stomatitis virus (Exotic)
Listed Plant Pathogens
Liberobacter africanus Liberobacter asiaticus Peronosclerospora philippinensis Phakopsora pachyrhizi Plum Pox Potyvirus	Ralstonia solanacearum race 3, biovar 2 Schlerophthora rayssiae var zeae Synchytrium endobioticum Xanthomonas oryzae Xylella fastidiosa (citrus variegated chlorosis strain)

Confirmation Code:*
Enter the code exactly as you see it.