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FORM CMP-

RESEARCH COMPLIANCE

DIVISION OF RESEARCH

State University of New York at Binghamton

INSTRUCTIONS

FOR COMPLETION OF NOTIFICATION OF POSSESSION OF SELECT AGENTS

OR HIGH CONSEQUENCE LIVESTOCK PATHOGENS AND TOXINS

All recipients of this form must complete boxes #1-6.

Review the agents listed in box #7 and check each agent or toxin used or possessed by your laboratory.

For each agent checked, check the appropriate descriptive category or categories, if known.

Definitions are listed below.

Provide the information in boxes #8-12. Check all boxes that apply.

If your laboratory does not possess any agents on this list, provide only the information requested in

boxes #13-15.

Do not report quantities of agents or toxins.

DEFINITIONS OF CATEGORIES:

Viable: Capable of replication on its own, in cell culture, or in an appropriate host.

Recombinant organism, Nucleic acid, or Genetic elements from agent include any of the following:

· Nonviable agents

· Full-length nucleic acid from any of the viruses on the list. For Variola major virus

(Smallpox), any segment that exceeds 100 nucleotides in length.

· Natural or synthetic nucleic acids from bacteria, fungi, or viruses on the list that encode for

either a functional toxin or virulence factor sufficient to cause disease, or natural or synthetic

nucleic acid that encodes for a functional toxin of any of the toxins listed, if: (1) expressed in

vivo; (2) in an expression vector or host chromosome; or (3) in a carrier plasmid.

Altered USDA or FDA approved vaccine strains: Vaccine strains that have been modified from

their original licensed, approved or registered forms.

PO Box 6000, Binghamton, NY, 13902-6000. Ph: 607-777- 4905 FORM CMP-

5 Revised 6/07/04

FORM CMP-

RESEARCH COMPLIANCE

DIVISION OF RESEARCH

State University of New York at Binghamton

NOTIFICATION OF POSSESSION OF SELECT AGENTS OR

HIGH CONSEQUENCE LIVESTOCK PATHOGENS AND TOXINS

1. Principal Investigator:

2. Department:

3. Laboratory Room Number(s):

4. Building:

5. Phone:

Fax:

6. E-mail:

Check "X" for each agent or Toxin Used or Possessed by Your Lab:

Viable

Recombinant

Organism, Nucleic

Acid or Genetic

Element from

Agent

Altered USDA or

FDA Approved

Vaccine Strains

Registered with

HHS Select

Agent Program

HHS Select Agents

CRIMEAN-CONGO HAEMORRHAGIC FEVER

VIRUS

EBOLA VIRUSES

LASSA FEVER VIRUS

MARBURG VIRUS

RICKETTSIA PROWAZEKII

RICKETTSIA RICKETTSII

SOUTH AMERICAN HAEMORRHAGIC FEVER

VIRUSES

TICK-BORNE ENCEPHALITIS COMPLEX

VIRUSES

VARIOLA MAJOR VIRUS (SMALLPOX VIRUS)

VIRUSES CAUSING HANTAVIRUS

PULMONARY SYNDROME

YELLOW FEVER VIRUS

YERSINIA PESTIS

ABRIN

CONOTOXINS

DIACETOXYSCIRPENOL

RICIN

SAXITOXIN

TETRODOTOXIN

USDA-HHS Overlap Agents

BACILLUS ANTHRACIS

BRUCELLA ABORTUS

BRUCELLA MELITENSIS

BRUCELLA SUIS

BURKHOLDERIA (PSEUDOMONAS) MALLEI

BURKHOLDERIA (PSEUDOMONAS)

PSEUDOMALLEI

CLOSTRIDIUM BOTULINUM

COCCIDIOIDES IMMITIS

COXIELLA BURNETII

EASTERN EQUINE ENCEPHALITIS VIRUS

EQUINE MORBILLIVIRUS (HENDRA VIRUS)

FRANCISELLA TULARENSIS

RIFT VALLEY FEVER VIRUS

VENEZUELAN EQUINE ENCEPHALITIS VIRUS

AFLATOXINS

BOTULINUM TOXINS

CLOSTRIDIUM PERFRINGENS EPSILON TOXIN

SHIGATOXIN

STAPHYLOCOCCAL ENTEROTOXIN

T-2 TOXIN

USDA High Consequence Livestock Pathogens and Toxins

AFRICAN HORSE SICKNESS VIRUS

AFRICAN SWINE FEVER VIRUS

AKABANE VIRUS

AVIAN INFLUENZA VIRUS (HIGHLY

PATHOGENIC)

BLUE TONGUE VIRUS (EXOTIC)

BOVINE SPONGIFORM ENCEPHALOPATHY

AGENT

CAMEL POX VIRUS

CLASSICAL SWINE FEVER VIRUS

COWDRIA RUMINANTIUM (HEARTWATER)

FOOT AND MOUTH DISEASE VIRUS

GOAT POX VIRUS

JAPANESE ENCEPHALITIS VIRUS

LUMPY SKIN DISEASE VIRUS

MALIGNANT CATARRHAL FEVER VIRUS

MENANGLE VIRUS

MYCOPLASMA CAPRICOLUM/M.F

38/M.MYCOIDES CAPRI (CONTAGIOUS

CAPRINE PLEUROPNEUMONIA AGENT)

MYCOPLASMA MYCOIDES MYCOIDES

(CONTAGIOUS BOVINE PLEUROPNEUMONIA

AGENT)

NEWCASTLE DISEASE VIRUS (EXOTIC)

NIPAH VIRUS

PESTE DES PETITS RUMINANTS VIRUS

RINDERPEST VIRUS

SHEEP POX VIRUS

SWINE VESICULAR DISEASE VIRUS

VESICULAR STOMATITIS VIRUS

8. Type of Work Performed by Laboratory:

Diagnostic Work

Large Scale Production

Vaccine

Development

Teaching

Research

Storage Only (No current work)

Use in animals

Other (Specify):

9. List all USDA Veterinary Permit Numbers for Importation and Transportation of Controlled Materials and Organisms

and Vectors Numbers (if applicable):

I hereby certify that I am the designated Responsible Party or Principal Investigator for the laboratory listed above, and

that the information supplied on this form is to the best of my knowledge accurate and truthful. I understand that a false

statement on any part of this form could result in a fine up to $500,000 or imprisonment of up to five years, or both for

each violation (18 USC1001; 18 USC 3559.3571)

10. Signature of Principal Investigator:

11. Print Name:

12. Date:

PO Box 6000, Binghamton, NY, 13902-6000. Ph: 607-777- 4905 FORM CMP-

5 Revised 6/07/04

DECLARATION OF NON-POSSESSION: THIS LABORATORY DOES NOT POSSESS AN AGENT ON THIS LIST.

I hereby certify that I am the designated Responsible Party or Principal Investigator for the laboratory listed above, and

that the information supplied on this form is to the best of my knowledge accurate and truthful. I understand that a false

statement on any part of this form could result in a fine up to $500,000 or imprisonment of up to five years, or both for

each violation (18 USC1001; 18 USC 3559.3571)

13. Signature of Principal Investigator:

14. Print Name:

15. Date:

Return this form by September 4, 2002, to:

Dr. Sharon Sickles

Office of Sponsored Programs

AD 242

PO Box 6000, Binghamton, NY, 13902-6000. Ph: 607-777- 4905

FORM CMP-

5 Revised 6/07/04

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