Form A - AQC - Contact Information

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The information provided in this checklist will help the Office of Biohazard Containment and Safety review the work objectives and program intent to determine the required Aquatic Animal Pathogen (AQC) level and provide recommendations on how to attain the desired AQC level.

Facility:

Room(s):

  • Postal Address:
  • Tel:
  • Fax:
  • E-mail:
  • Website:

Contact Information:

1) Facility Supervisor (main contact)

  • Name:
  • Title:
  • Department:
  • Address:
  • Phone number:
  • Fax number:
  • E-mail:
  • Language preference: checkbox English / checkbox Français
  • Other comments:

Signature: Date:

2) Biosafety Officer (or equivalent)

  • Name:
  • Title:
  • Department:
  • Address:
  • Phone number:
  • Fax number:
  • E-mail:
  • Language preference: checkbox English / checkbox Français
  • Other comments:

Signature: Date:

Type of Facility:

  • Government (federal)
  • Government (provincial)
  • University
  • Hospital
  • Private
  • Other

Modifications:

  • Upgrading Existing Facility
  • Renovations
  • New Construction Site
  • Other

Program Intent

(brief description of the type of work [research, diagnostic, production] and list procedures with the potential to generate aerosols):

Scale/Volume:

  • Laboratory
  • Large Scale

Comments:

Other

Pathogens:

  • Affecting Humans - Yes checkbox   No checkbox
  • Affecting Animals/Fish - Yes checkbox   No checkbox

Comments:

List of Pathogens

(species and subtypes where applicable):

Use of Animals:

Yes checkbox   No checkbox

Species and quantity:

Internal Use Only

Assessment of required AQC level:

checkbox AQC-1 checkbox AQC-2 checkbox AQC-2 in vivo checkbox AQC-3 checkbox AQC-3 in vivo
checkbox work with Veterinary Biologics

Comments:


Signature: Office of Biohazard Containment Safety (OBCS)


Date


Signature: Aquatic Animal Health Division (AAHD)


Date


Signature: Veterinary Biologics Section (VBS)


Date

Date modified: