Continuation Form - Section D

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

CONTINUATION PAGE FOR APPLICATION FOR PERMIT TO IMPORT INFECTIOUS BIOLOGICAL AGENTS INTO THE UNITED STATES

FORM APPROVED OMB NO. 0920-0199 EXP DATE xxxx

Continuation Page of continuation pages

SECTION D continuation (Other Final Destinations of Imported Biological Agent)
1. Last Name of Recipient at Other Final Destination		2. First Name				3. MI	4. Destination Organization
5. Final Destination Address (NOT a post office box)					6. City					7. State	8. Zip Code
9. Telephone			10. Fax					11. Email
SECTION E continuation (Description of Imported Biological Agent)
1. Intended use(s) of imported agent(s) Diagnostic Education Research Production Clinical trials Other (please describe):			2. Provide a detailed description of the work to be accomplished with the imported agent(s) (Describe your work clearly & simply. Include background, purpose, objectives, methods, etc.)
SECTION G continuation (Biosafety Measures)
1. Primary Containment to be used (Check all that apply) None (open bench) Class I Class II, Type Class III Fume Hood Other (please describe):	2. Personal Protective Measures to be used (Check all that apply) Gloves Protective Clothing Goggles and/or Face Shield Facemask Respirators: Type N95/100 PAPR Immunizations Other (please describe):			3. Personnel Training provided (Check all that apply) Risk(s) associated with the imported biological agent(s) Hazardous Material Packing/Shipping Laboratory Standard Practices Hazardous Waste Handling/Disposal Emergency Response Procedures Spill Procedures Other (please describe):					4. Has the permittee implemented biosafety measures commensurate with the hazard posed by the infectious biological agent, infectious substance, and/or vector to be imported, and the level of risk given its intended use? No Yes (Plan may be required to be submitted)