Human/Animal Tissue Use Registration Form This form is required for research involving fresh/frozen tissue (including primary cell lines, human and other primate established cell lines and tissue cultures), blood, blood products, and body fluids If the research involves living organisms, approvals from relevant committees may be required (e.g Institutional Animal Care and Use Committee, Institutional Review Board) Principal Investigator Name: Department : Laboratory Location: Funding Agency: Project Title/ Course#: E-mail: Phone: What type of tissue will be used in this study? Check all that apply Fresh or frozen tissue sample Fresh organ or other body part Blood Body fluids Primary cell/tissue cultures Human or other primate established cell lines Where will the above tissue be obtained? Provide a brief summary of the proposed use of tissue in layman’s terms (approximately 3-5 sentences) Provide a brief summary of how tissues will be stored and what personal protective equipment will be used 10 Applicant’s Assurance I certify that: a if animals were euthanized, they were euthanized for a purpose other than research OR they were obtained from an IACUC approved research protocol b blood, blood products, tissues, or body fluids in this project will be handled in accordance with the standards and guidance set forth in the U.S Occupational Safety and Health Administration’s Blood Borne Pathogens standard (29CFR, Subpart Z, 1910.1030) c personnel having contact with potentially infectious tissues or fluids will submit a Medical Health & Risk Assessment Form Electronic Signature of Principal Investigator Date Submit this completed form electronically to kgillespie@middlebury.edu Human/Animal Tissue Use Registration Form, 01-2019 Middlebury College