Form code: WS2.ECACC/028/05

To be completed prior to acceptance of a biological agent into an ECACC repository
For ECACC use only Type of Deposit: ....................................................................................................................................... Accession Number: ....................................................................................................................................... Depositor Code: ....................................................................................................................................... Activity Class: ....................................................................................................................................... Signed: ....................................................................................................................................... Date: .......................................................................................................................................
For Completion by Depositor
The Biological Agent is:	Animal Cell  Virus  Bacterium  Yeast  Plasmid
Genetically Modified:	Yes No  If yes. What Class
	If you have answered Class 2 or above please forward to us any Risk Assessment you have carried out yourselves relating to this deposit.
Other (please define):
Species:
Strain:
Identification Code:
ACDP Hazard Group1	1 2 3 4 If USA deposit use SALS Category
Does this require a Specified Animal Pathogens Order	Yes No  If yes please refer to the DEFRA Web site for a licence application. www.defra.gov.uk
	1 ACDP Advisory Committee on Dangerous Pathogens Hazard Group 1 A biological agent unlikely to cause human disease. Hazard Group 2 A biological agent that can cause human disease and may be a hazard to employees, it is unlikely to spread to the community and there is usually effective prohpylaxis and effective treatment available. Hazard Group 3 A biological agent that can cause severe human disease and presents a serious hazard to employees. It may present a risk of spreading to the community, but there may be a prophylaxi or treatment available. Hazard Group 4 A biological agent that causes severe human disease and is a serious hazard to employees. It is likely to spread to the community and there is usually no effective phophylaxis or treatment available.
Brief description of deposit.  If the agent is genetically modified include details of inserted gene, method/vehicle for insertion and any expression product.
To be completed if the biological agent is genetically modified
1.    The host organism is ACDP Hazard Group 1 2 3 4 2.    Does the GM agent contain/produce a biologically active substance that could potentially cause harm to humans (e.g. toxin, cytokine, hormone, allergen, oncogene) Yes No 3.    What is the likelihood that the genetic modification can confer pathogenic traits in the host organism? Negligible Possible Probably or Demonstrated If 'possible', 'probably' or 'demonstrated' please provide additional details: 4.    What is the potential for sequences within the GM being transferred to another related microorganism? Negligible Low Medium High If 'medium' or 'high' please provide additional details: 5.    In the light of your knowledge of this GMM and its origination, what is your assessment of its potential to cause harm to human health in the event of exposure? Negligible Low Medium High If 'medium' or 'high' please provide additional details: 6.    Does this GMM have the ability tosurvive, establish and disseminate in the environment? Yes No
Form completed by:
Name:
Title:
Date:
	NOTE: Please sign on the printed form where indicated
ECACC may request further information in order to complete its risk assessment. To whom should such requests be addressed?
Name:
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