Biohazard Risk Assessment Form

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Biohazard Risk Assessment Form

	For HPA Culture Collections use only
	Type of Deposit:
	Accession Number:
	Quote Number:
	ACDP Hazard Group:
	Containment Level:
	ECACC Risk Assessment required:
	Signed:
	Date:

	For Completion by Depositor. Complete all questions (1-16) if the deposit has an associated pathogen or is genetically modified. Otherwise complete questions 1-11 & 16.
	Form Completed by
	Name:
	Job Title:
	Organisation Name:
	Contact Tel:
	Contact Email:

1.	Deposit Type: Deposit Name:
2.	Tissue Type (if applicable):
3.	Species:
4.	Morphology:
5.	If deposit is a cell line, is the cell line known to contain or secrete a virus or virus-like particles?
		Yes No
5.1	If Yes, is the virus of a known pathogenic type or potentially pathogenic to animals or humans?
		Yes No
	Please give details of any virus or virus-like particles known to be associated with cell line:
5.2	If No for question 5, indicate reason for believing by giving details of any tests performed:
6.	Does the deposit, e.g. cell line, contain/produce a biologically active substance that could potentially cause harm to humans (e.g. toxin, cytokine, hormone, allergen, oncogene, virus)?
		Yes No
7.	Provide a brief description of known associated pathogens or genetic modifications:
8.	Are you supplying any Risk Assessment performed at your site? (If yes, please attach to the hardcopy of this form that you provide to us)
		Yes No
9.	Is the Deposit Genetically Modified?	Yes No
	If Yes, what class?
10.	What ACDP Hazard Group* does the deposit belong to?
		1 2 3 4

	*ACDP = Advisory Committee on Dangerous Pathogens
	Hazard Group 1	A biological agent unlikely to cause human disease.
	Hazard Group 2	A biological agent that can cause human disease and may be a hazard to employees, it is unlikely to spread to the community and there is usually effective prophylaxis and effective treatment available.
	Hazard Group 3	A biological agent that can cause severe disease and presents a serious hazard to employees. It may present a risk of spreading to the community, but there may be a prophylaxis or treatment.
	Hazard Group 4	A biological agent that causes severe human disease and is a serious hazard to employees. It is likely to spread to the community and there is usually no effective prophylaxis or treatment available.

11.	If you are sending ampoules, are they glass or plastic?
12.	Does the deposit require a Specified Animal Pathogens Order? (If yes, please refer to the DEFRA website where you can download a licence application: www.defra.gov.uk)
		Yes No
13.	What is the likelihood that the associated pathogen or genetic modification can confer pathogenic traits in the host organism?
	Negligible Possible Demonstrated If 'possible' or 'demonstrated' please provide additional details:
14.	What is the potential for sequences in the deposit being transferred to another related organism?
	Negligible Low Medium High If 'medium' or 'high' please provide additional details:
15.	In light of your knowledge of this deposit and its origination, what is your assessment of its potential to cause harm to human health in the event of exposure?
	Negligible Low Medium High If 'medium' or 'high' please provide additional details:
16.	Does this deposit have the ability to survive, establish and disseminate in the environment?
		Yes No
17.	HPA Culture Collections may request futher information in order to complete its risk assessment. To whom should such requests be addressed?
	Name:
	Telephone:
	Fax:
	Email:

You can submit this form online but we will need a signed version - therefore, fax your completed Biohazard Risk Assessment Form to HPA Culture Collections on +44 (0) 1980 611315 or post the form using the address details on the 'Contact Us' page of this website.
Await notification and approval from HPA Culture Collections prior to sending samples.

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Biohazard Risk Assessment Form

Biohazard Risk Assessment Form