Human and Vertebrate Animal Tissue Form (6B)
Required for research involving fresh/frozen tissue (including primary cell lines, human and other primate established cell lines and
tissue cultures), blood, blood products and body fl uids. If the research involves living organisms please ensure that the proper human
or animal forms are completed. All projects using any tissue listed above must also complete Form 6A.
Student’s Name(s)
Title of Project
To be completed by Student Researcher(s):
1.
What vertebrate animal tissue will be used in this study? Check all that apply.
Fresh or frozen tissue sample
Fresh organ or other body part
Blood
Body fl uids
Primary cell/tissue cultures
Human or other primate established cell lines
2. Where will the above tissue(s) be obtained. If using an established cell line include source and catalog number.
3. If the tissue will be obtained from a vertebrate animal study conducted at a research institution attach a copy of the
IACUC certifi cation with the name of the research institution, the title of the study, the IACUC approval number and
date of IACUC approval.
To be completed by the Qualifi ed Scientist or Designated Supervisor:
I verify that the student will work solely with organs, tissues, cultures or cells that will be supplied to him/her by myself or
qualifi ed personnel from the laboratory; and that if vertebrate animals were euthanized they were euthanized for a purpose
other than the student’s research.
AND/OR
I certify that the blood, blood products, tissues or body fl uids in this project will be handled in accordance with the standards
and guidance set forth in Occupational Safety and Health Act, 29CFR, Subpart Z, 1910.1030 - Blood Borne Pathogens.
Printed Name
Signature
Date of Approval
(Must be prior to experimentation.)
Title
Phone/Email
Institution
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