University of California, Davis
Contained Research Facility
Application for Space
Contact: Sandy Kelley, Manager (530.754.2104)
SECTION 1. Principal Investigator and Laboratory Personnel Information
Project Title:
Project Start Date:
For Office Use Only
Project End Date:
Date Application Received:
Funding Source:
Received By:
Principal Investigator:
Department:
Phone:
Title:
Building:
Fax:
Room:
E-mail address:
After Hours Contact Information:
Assistant
Title:
Co-Investigator
Department:
Phone:
Building:
Fax:
Room:
E-mail address:
After Hours Contact Information:
Assistant
Title:
Co-Investigator
Department:
Phone:
Building:
Fax:
Room:
E-mail address:
After Hours Contact Information:
Principal Investigator signature:
Date:
Co-Investigator /Assistant signature:
Date:
Co-Investigator /Assistant signature:
Date:
SECTION 2. Project Information
1. Research project summary. Describe your project objectives, experimental organisms, experimental design, and methods.
Be specific.
2. Risk assessment. List all safety hazards associated with your project, affecting humans and animals, due to experimental
organisms, hazardous chemicals, and breach of containment. (Include others, if pertinent.)
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3. Risk minimization. Describe how your organism(s) will be transported or shipped to the CRF, and how it will be housed
once inside the facility (e.g., cage within a cage, cage within a growth chamber, etc.). Describe cage(s) to include size and
composition.
4. Equipment and Supplies. List all equipment and supplies needed to conduct your project. Be specific.
5. If you anticipate a need to remove any physical material from the BSL3-Plant area, describe what you need to
remove and provide a detailed justification. Include supporting data indicating why there is no risk associated with
removing the material from the facility. Explain how the material will be used upon leaving the CRF. Describe what
measures will be taken to ensure the material is not released and/or distributed to others.
6. Anticipated timeline of project (Note: Projects will be reviewed at six months for progress and use of space):
SECTION 3. Experimental Organisms
Name (scientific and common):
Host Range:
Natural Geographic Range:
Source:
Environmental requirements:
Temperature (min/max):
Light (day/night):
Other:
Name (scientific and common):
List the temperature and kill time (cite the source of the information):
Natural Geographic Range:
Source:
Environmental requirements:
Temperature (min/max):
Light (day/night):
Other:
Name (scientific and common):
List the temperature and kill time (cite the source of the information):
Natural Geographic Range:
Source:
Host Range:
Host Range:
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Environmental requirements:
Temperature (min/max):
Light (day/night):
Other:
Name (scientific and common):
List the temperature and kill time (cite the source of the information):
Natural Geographic Range:
Source:
Environmental requirements:
Temperature (min/max):
Light (day/night):
Other:
List the temperature and kill time (cite the source of the information):
Host Range:
Section 4. Permits
Agency permits*
APHIS
CDFA
BUA
Permit Type
Permit No.
Issuance Date
Expiration Date
(form 526)
(form 66-026)
(campus EH&S)
*Attach a copy of the permit
.
SECTION 5. Space Request
Type of Space
Amount of Space
Section 6. Billing Information
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Duration
Accountant’s Name and Department:
Phone:
DAFIS number:
Fax:
email:
Section 7. Application Checklist
Be sure to include the following when submitting your application packet:
□ Copy of current Biological Use Authorization or EH&S exemption for this project
□ Copy of current APHIS permit (form 526) and/or CDFA permit (form 66-026)
□ Completed CRF Application for Space; please submit six hard copies, and
one electronic copy to [email protected]
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