Notification of Potential Dual Use Research of Concern (DURC) Form Notification of Potential DURC Form 1. Contact Information 1.1 Principal Investigator (PI)PI Name:* First Last PI Phone:*PI Email:* Submitter Name First Last Submitter PhoneSubmitter Email 2. Project Information Please identify any life sciences research you conduct at this institution that directly involves nonattenuated forms of one or more of the agents listed below (please use a separate form for each identified project). If none of the agents are identified, your research is not subject to institutional DURC oversight. However, PIs should be aware that, if at any time, research is initiated that involves any of the below listed agents, he or she will need to immediately notify the institutional review entity (or appropriate institutional authority), per the policy of this institution.2.1 Project Title(s):*2.2 Agent or Toxin Involved in Project (Check All That Apply)* Avian influenza virus (highly pathogenic) Botulinum neurotoxin (any quantity) Burkholderia pseudomallei Foot-and-mouth disease virus Marburg virus Rinderpest virus Variola major virus Yersinia pestis Bacillus anthracis Burkholderia mallei Ebola Virus Francisella tularensis Reconstructed 1918 influenza virus Toxin-producing strains of Clostridium botulinum Variola minor virus None of the above 2.3 Type of Funding Source(s) for This Project* Departmental / Institutional Funds Foundation Federal funds Business/industry Other *If project is supported with Federal funds, name of funding agency and grant or contract number: 3. Training of Laboratory Personnel The Policy for Institutional DURC Oversight requires that all laboratory personnel (i.e., those under the supervision of laboratory leadership, including graduate students, postdoctoral students, postdoctoral fellows, research technicians, laboratory staff, and visiting scientists) conducting research with nonattenuated forms of 1 or more of the 15 listed agents have received education and training on DURC.Please indicate whether the following laboratory personnel involved in this project have received DURC training:Was the PI Trained?* Yes No Date of PI Training (if applicable): MM slash DD slash YYYY Were lab staff trained?* Yes No Date of Lab Staff Training (if applicable): MM slash DD slash YYYY Are there additional lab staff that require training?* Yes No Does the research enhance the harmful consequences of the agent or toxin? Please explain.Does the research disrupt immunity or the effectiveness of an immunization against the agent or toxin without clinical or agricultural justification? Please explain.Does the research confer to the agent or toxin resistance to clinically or agriculturally useful prophylactic or therapeutic interventions against that agent or toxin or facilitates its ability to evade detection methodologies? Please explain.Does the research alter properties of the agent or toxin in a manner that would enhance its stability, transmissibility, or ability to be disseminated? Please explain.Does the research alter the host range or tropism of the agent or toxin? Please explain.Does the research enhance the susceptibility of a host population to the agent or toxin? Please explain.Does the research generate or reconstitute an eradicated or extinct agent or toxin listed in Section 2.2 of this form? Please explain.As a reminder, if there is a change in this research with respect to the applicability of any of the seven experimental effects, or if the PI, for any reason, thinks the research needs to be reconsidered by the IRE for DURC potential, the PI should submit this form again with his/her revised assessment.