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Bloodborne Pathogens Registration Form
Sep 06,2012 at 04:08:PM

In order to ensure compliance with the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard (29CFR1910.1003), Principal Investigators must notify the Syracuse University's Microbiological Safety Committee prior to the use of blood and other potentially infectious material on campus. Annual "Bloodborne Pathogens Training", available through EHSS, is required for SU employees with occupational exposure to blood and other potentially infectious material.

Please complete the form below to indicate the presence or absence of the listed items, in University facilities under your control or supervision.

You may submit this form electronically or you may print and submit it in paper form to the Environmental Health and Safety Services Office, 029 Lyman Hall, Attention: Tim Coughlin.

Thank you.

Questions? Call Tim Coughlin at 443-2447.

Principal Investigator:
Department:
Phone Number:

Using the checkboxes below, please indicate if research you conduct, or oversee,
uses human blood or other potentially infectious materials.

No Answer          
          HUMAN BLOOD
Yes   No   Whole human blood, any of its parts (serum, platelets, etc.),
products made from human blood, or any human body fluids contaminated with blood.
           
          POTENTIALLY INFECTIOUS HUMAN MATERIAL
Yes   No   Human semen, vaginal secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid,
saliva in dental procedures, any body fluid that is visibly contaminated with blood,
and all body fluids in situations where it is difficult to differentiate between body fluids.
Yes   No   Any unfixed tissue or organ (other than intact skin) from a human (living or dead)
Yes   No   HIV-containing cell or tissue cultures, organ cultures,
and HIV- or HBV- or HCV-containing culture medium or other solutions.
           
          POTENTIALLY INFECTIOUS ANIMAL MATERIAL
Yes   No   Blood, organs, or other tissues from experimental animals infected with HIV, HBV or HCV.
 
Yes   No   Blood, organs, other tissues, or waste products from experimental animals infected with a human pathogen.
If yes, please list host animal and pathogen:
         
Animal Pathogen

Certification

I have read and answered all applicable questions
and assure that all statements made are accurate
and account for all experiments being conducted by me, or under my supervision.

I understand that any modification made to experiments that may change the answers to the above questions will require formal notification to the Microbiological Safety Committee prior to implementing the modification.

Printed Name:

Signature:
(If filling this form out on the web, please enter your SU ID# instead.)

Date:

E-mail:

 

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