University of Stellenbosch Flow Cytometry Unit

The University of Stellenbosch Flow Cytometry Unit is a multi-user facility where many different samples from various sources, that may contain known or unknown human pathogens, are investigated. The safety of the staff and of users of the facility is of ultimate concern. Information about the sample sources and potentially infectious agents is critical for effective biosafety measures.

Consequently, the Sample Information Form (SIF) below must be filled out completely and signed by the Principle Investigator who is requesting samples to be analyzed or sorted in the Flow Cytometry Unit, before experiments or projects are started. Print this page, complete the questions, sign and date it and return to Christo Muller. The same biosafety questionnaire will be kept on file, provided none of the information it contains has changed. Appropriate biosafety approval of experiments, prior to sample submission to the Unit, is an absolute requirement.

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Principal Investigator (Laboratory Director)
Phone number:
Fax number:
E-mail:

Investigator:
Phone Number:
Fax Number:
E-mail:
Laboratory Location (Building and Room):

• Project title
• Summary or description of project (provide details related to samples that will be analyzed or sorted. Limit to one paragraph)
• List type of sample and source: (e.g. mouse spleen cells, human peripheral blood mononuclear cells, cells from an animal en-grafted with human cells, etc. For cell lines, describe cell origin)
• Does the sample contain any known infectious agent(s)?
• List agent(s)
• Provide Biosafety Level of agents using classifications as listed in “Biosafety in Microbiological and Biomedical Laboratories”, US Department of Health and Human Services, 4th edition
• Has the infectious agent been inactivated?
• If YES, describe method of inactivation
• Provide proof of inactivation, if applicable
• Were blood cell donors screened for blood-borne pathogens (e.g., TB, HIV, HBV, HCV)?
• If YES, list test results, positive and negative
• Could the sample contain other known human pathogens?
• If YES, list agent(s)
• Were the cells transformed using a virus(such as EBV, HTLV-1, herpes saimirii)?
• If YES, list virus
• Were cells genetically engineered?
• How were they genetically engineered?
• Was a gene therapy virus (adenovirus, retrovirus, lentivirus, herpesvirus, etc.) used to transfer genetic information to the cells?
• If YES, describe method in detail, attach vector map and show packaging cell line
• Have the cells been tested for mycoplasma infection and/or viral infection (HIV, HBV, SIV, etc.)?
• If YES, give date(s) of last test(s)and test(s) result(s) (tests must have been performed just prior to sample submission to the Flow Cytometry Unit)
• Will the samples be fixed prior to submission to Flow Cytometry Unit?
• Describe the fixation protocol in detail (e.g., list concentration and exposure time)

I have read and answered the above questions carefully and certify the information provided to be correct

_____________________________ Signature (Principal Investigator)

_____________________________ Date