Biohazard Risk Assessment Worksheet
Directions: 1. Read the information provided in the risk assessment
2. Complete all information highlighted in yellow.
3. The PI must sign in the designated areas, confirming that the procedures provided
are understood, and will be followed.
4. Submit the completed form to
Agent Identification
Name: (genus/species or PrP isoform)
o
Type of Agent: (circle all that apply): The selected agents are “potential agents” that may be present
Bacterium (potential) / PrionFungus / Rickettsia
Parasite (potential) / Toxin derived from living organism
Virus (potential)
Disease(s) caused by agent: Unknown – potentially various viruses, Hepatitis B, C, HIV, EBV and tumor production. Potentially bacterial and parasitic diseases.
Health Hazards
Pathogenicity:
Potential pathogen
Pathogenic
Highly pathogenic
Opportunistic pathogen
Other: potentially tumorogenic
Epidemiology:
Host Range: (check all that apply)
humans
animals (specify) potentially
plants
Infectious Dose:
known
unknown
Mode of Transmission: (check all that apply)
Direct Contact
human/human – through bodily fluids
human/animal
Indirect Contact
vector-borne
inanimate objects
food, water, air
Route of Entry: (check all that apply)
ingestion
inhalation
penetration through skin
contact with mucous membranes of eyes, nose, and mouth
Incubation Period: unknown/variable
Communicability:
person-to-person transfer – by bodily fluids
no evidence of person to person transfer
suspected person-to-person transfer
Dissemination
Reservoir: Specimens, samples or cultures in lab
Zoonosis:
Unknown
No
Yes
Vectors:
Unknown
None
Yes
Viability
Drug Susceptibility:
Variable based on pathogen.
Disinfectant Susceptibility: 70% ethanol, .1% sodium hypochlorite (1:50 dilution household bleach) Add other specific disinfectants for your lab:
Physical Inactivation: autoclaving at 121C for 15- 30 minutes
Survival outside Host: Unknown
Medical
Surveillance: Self monitor for redness and swelling in affected area.
First Aid/Treatment: accidental self inoculation - Immediately wash affected area with soap and water. Make the site bleed a little to help flush out any material. Inform supervisor and get medical attention if needed. Consult with occupational or other physician.
Immunization:
Hepatitis B vaccine
Prophylaxis: Variable based on pathogen and disease. Will be determined by physicians orders.
Laboratory Hazards
Laboratory-Acquired Infections (epidemiology of lab-acquired infections):
Those caused by bloodborne pathogens (HIV, HBV, HCV, EPV), bacteria or parasites
Potential for tumor production
Sources/Specimens:
Specify source of material:
Primary Hazards:
Self inoculation or spill on an open wound, cut of scratch.
Splash to eyes or mucous membrane
Special
List any specific hazards involved with your work:
Recommended Precautions
Containment Requirements: I confirm that all work with human cell lines will occur at Biosaftey Level 2:
PI electronic signature:
Personal Protective Equipment: Lab coat and gloves. Any open wound, cut or scratch will be covered with a bandage. Eye protection will be worn if any procedures are done outside the biosafety cabinet which may produce a splash. I confirm that this is the minimum PPE that will be used:
PI electronic signature:
Other Precautions: Work will be performed in a biosafety cabinet. Sharps use will be kept to the absolute minimum. Plastic ware will be used whenever possible. Needles used to inoculate mice will be placed directly into sharps container or the one handed recapping method used.
Add any other lab specific precautions:
I confirm that these precautions will be used:
PI electronic signature:
Handling Information
Spills:
Inform others in the area of the spill. Place paper towels on spill. Leave area if large spill. Remove contaminated PPE. Don clean PPE (lab coat, gloves, eye protection/ splash protection). Pour disinfectant ( 1% sodium hypochlorite – 1:5 dilution household bleach) on area. Wait 10 minutes. Clean up and repeat as needed.
Disposal:
All solid waste will be collected in orange biohazard autoclave bags, autoclaved and disposed of in regulated medical waste (RMW) as per EHS.
Sharps will be collected in sharps containers, autoclaved and placed into RMW.
Liquid waste will be diluted with household bleach (1:5). Allowed to sit for 10 minutes and poured down the drain followed by water.
Storage: sealed tubes in freezer labeled with biohazard sticker
no special requirements
Miscellaneous Information/References
Personnel working with human and non-human primate blood, blood products, tissues and body fluids must complete Bloodborne pathogen training annually.
Congratulations! You now have a material safety data sheet for your biological agent.
EHS Form (06-11)
Risk Assessment Worksheet