Recombinant DNA and Synthetic Nucleic Acid Incident Reporting Template

Institution: *

Date of incident: *

Is this an NIH funded project?

Yes

No

NIH grant or contract number:

NIH funding institute or center:

NIH program officer contact information (name, email, etc.):

What was the nature of the incident? *

Personnel exposure

Spill

Loss of containment

Loss of transgenic animal

Failure to obtain IBC approval

Failure to follow approved containment

Other - please describe:Other - please describe:

Did the Institutional Biosafety Committee (IBC) approve this research? *

Yes

No

Approval date:

Approved biosafety level of research:

Additional approval requirements:

What section of the NIH Guidelines is the research subject to?

Has a report of this incident been made to other federal or local agencies? If so, please indicate by checking the appropriate box.

Has a root cause for this incident been identified? *

Yes

No

(possible issues include level of training communications, awareness of hazards, etc.)

Please describe the root cause:

Describe measures taken to mitigate any problems identified. For measures identified but not yet taken, please include a timeline for their implementation:

Please provide a narrative of the incident including a timeline of events. The incident should be described in sufficient detail to all for an understanding of the nature and consequences of the incident. Include the following information as applicable.

A description of:

The recombinant agent or material involved.
The incident/violation location (e.g. laboratory biosafety level, vivarium, non-laboratory space).
Who was involved in the incident/violation, including others present at the incident location? Note: please do not identify individuals by name; provide only position titles.
Actions taken immediately following the incident/violation, and by whom, to limit any health or environmental consequences of the event.
The training received by the individual(s) involved and the date(s) the training was conducted.
The institutional or laboratory standard operating procedures (SOPs) for the research and whether there was any deviation from these SOPs at the time of the incident/violation.
Any deviation from the IBC approved containment level or other IBC approval conditions at the time of the incident/violation.
The personal protective equipment in use at the time of the incident/violation.
The occupational health requirements for laboratory personnel involved in the research.
Any medical advice/treatment/surveillance provided or recommended after the incident.
Any injury or illness associated with the incident.
Medical surveillance results (if not available at the time of the initial report please indicate when the results will be available).
Equipment failures.

Description of incident:

PI Signature:

Date:

By checking this box I verify that I am the Principal Investigatory responsible for the research above.

Verify

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