UCSC SSCF Safety Questionnaire

The purpose of this form is to determine what degree of health and safety training is appropriate to maintain a safe research environment of all researches in the stem cell core facility. To the best of your ability, please provide as much information as possible for each member of you laboratory so that the SSCF manager can help design and maintain a training regimen that provides that greatest access to the features of the core facility for your staff while maintaining a safe environment for researchers from different labs that are working in common areas. Individual PI BUA approval is required for certain works listed on this form.

At a minimum, you will be asked to provide documentation to certify appropriate training in general lab safety, chemical and biological waste and blood born pathogens for all of your lab members associated with your project. Please notify the SSCF Manager prior to making any changes in research techniques or staff members.
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Email *
Principal Investigator
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Project Title
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Start Date
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End Date
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Project Description
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Student Researchers
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Postdoctoral / Staff Researchers
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Biosafety Considerations and Risk Levels
Please indicate all cell types you will be working with *
Required
Do you plan to introduce DNA into ES cells? *
Do you intend to use whole blood or tissues?
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If yes, please describe
Do you plan to use oncogeneic transgenes? *
Do you intend to use viral vectors?
 *
If yes, please indicate which viral vectors?
Do you plan to utilize viral vectors on a permissive host/ permissive cell line? *
Do you plan to GENERATE viral vectors? *
If yes, please describe
Where will viral vectors be made and stored?
Please describe your viral packaging system (ie. AAV-9)
Do you intend to conduct xenogenic studies (ie. chimeras involving human cells)? *
Acknowledgement
To the best of my knowledge, the above information is correct and I understand that using materials other than those outlined above may result in loss of facility use privileges.
PI SIGNATURE
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