{"id":3083,"date":"2017-10-05T08:58:44","date_gmt":"2017-10-05T13:58:44","guid":{"rendered":"https:\/\/uwm.edu\/safety-health\/?page_id=3083"},"modified":"2024-10-28T14:14:41","modified_gmt":"2024-10-28T19:14:41","slug":"initial-report","status":"publish","type":"page","link":"https:\/\/uwm.edu\/safety-health\/biosafety\/initial-report\/","title":{"rendered":"Initial Report of Biological Exposure or Release Event AND Near Misses"},"content":{"rendered":"<p>This report, when submitted, provides the University Safety and Assurances Department, Biological Safety Program, and the Institutional Biosafety Committee with information to ensure that proper actions have been taken, including appropriate medical care, and helps the University meet National Institutes of Health reporting requirements.<\/p>\n<h1>INSTRUCTIONS<\/h1>\n<ul>\n<li><strong>If you have an approved biosafety protocol, please go to <a href=\"https:\/\/uwm.my.irbmanager.com\/Login.aspx?clientid=uwm\">IManager<\/a> and submit the xForm in your protocol. Just log in, select the protocol number, and when viewing that protocol, select &#8220;Start xForm in the left column&#8221; and select the Biosafety Initial Report of Biological Exposure or Release Event AND Near Misses xForm to complete.\u00a0<\/strong><\/li>\n<li>Use this form to report any and all potential exposures or releases of\u00a0<strong>organisms<\/strong>\u00a0or\u00a0<strong>biological toxins<\/strong>\u00a0on 51ÁÔÆæ main campus and its extension facilities, including the School of Freshwater Science, Global Water Accelerator, and the Innovation Accelerator.<\/li>\n<li>Reporting should be completed within 24 hours of the event, and is the responsibility of the Principal Investigator.<\/li>\n<li>Potential exposures include needle sticks, animal bites, aerosol exposures, and other incidents potentially resulting in disease.<\/li>\n<li>Potential releases include spills outside of primary containment as well as potential releases to the environment.<\/li>\n<li>Unauthorized releases of\u00a0<strong>transgenic animals or plants<\/strong>\u00a0should also be reported on this form.<\/li>\n<li>After completing this form, select \u201cSubmit\u201d at the bottom of this form. The information on this form will be sent to the 51ÁÔÆæ Biological Safety Officer.<\/li>\n<li>Information on this form is used to determine how our offices may help you and your laboratory and for mandatory federal reporting purposes.<\/li>\n<li>The submitter will be contacted for incident follow-up.<\/li>\n<li>If you need assistance completing this form or reporting an incident, please call the Biological Safety Officer at <a href=\"mailto:uwm-biosafety@uwm.edu\">uwm-biosafety@uwm.edu<\/a>.<\/li>\n<li><strong>If anyone was injured in the incident, please complete:<\/strong>\n<ul>\n<li><strong>Employee: <a href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/new_ee_injury_form\/Employee's%20Work%20Injury%20and%20Illness%20Form.pdf\">Employee\u2019s Work Injury and Illness Report\u00a0<\/a><\/strong><\/li>\n<li><strong>Employer: <a href=\"https:\/\/panthers.sharepoint.com\/:b:\/s\/USA\/EflH_gPQsiRFk7U3b83qUEkB36pjDR3seBDb-wvDybeugQ?e=MeaiNx\">Employer\u2019s First Report of Injury or Disease<\/a><\/strong><\/li>\n<li><strong>Supervisor: <a href=\"https:\/\/www.wisconsin.edu\/workers-compensation\/download\/supervisor_forms\/Supervisor%20Accident%20Analysis.pdf\">Supervisor\u2019s Accident Analysis and Prevention Report and Evaluation of Repetitive Motion and\/or Materials Handling Activities\u00a0<\/a><\/strong><\/li>\n<li><strong>Student Injuries: <a href=\"https:\/\/panthers.sharepoint.com\/sites\/USA\/_layouts\/15\/guestaccess.aspx?guestaccesstoken=DTMth%2f2z01T95m3IwBFqT2E4aP7X0BnjA0NxmA5luHg%3d&amp;docid=02610b8108e8d46ea94a9f1a42ac236f9&amp;rev=1\">General Incident Report 300A2 for student injuries or incidents<\/a><\/strong><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<hr \/>\n<div id=\"gform_wrapper_25\" class=\"gf_browser_chrome gform_wrapper\">\n<div class=\"gform_body\">\n<ul id=\"gform_fields_25\" class=\"gform_fields top_label form_sublabel_below description_below\">\n<li id=\"field_25_1\" class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\">Please fill in <b>all <\/b>*<i>Required<\/i>\u00a0fields before submitting the form.<\/li>\n<\/ul>\n<\/div>\n<p>&nbsp;<\/p>\n<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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Event<\/h3>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/safety-health\/wp-json\/wp\/v2\/pages\/3083' data-formid='6' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Let4LkmAAAAAMDytJZITec55NB97k2BiShMXqPE' data-tabindex='0'><input id=\"input_4a79835752d484794e1f1310d08e6042\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_4a79835752d484794e1f1310d08e6042\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_6_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Principal Investigator Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_2\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_2'>Principal Investigator Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_2' id='input_6_2' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_3\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Contact Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_3'>\n                            \n                            <span id='input_6_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_6_3_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_3_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_6_3_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_6_3_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_4'>Contact Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_6_4' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_5\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_6_5' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_6\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_6'>Department<\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_6_6' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_7\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_7'>Location of Event<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_7' id='input_6_7' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_8\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_8'>Nature of Event (explain what happened and how it occurred)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_8' id='input_6_8' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_9\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_9'>Date of Event (MM\/DD\/YYYY)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_6_9' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_6_9_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_9_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_9' class='gform_hidden' value='https:\/\/uwm.edu\/safety-health\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_10\" class=\"gfield gfield--type-time gfield--input-type-time field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Time of Event<\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_6_10'>\n                            <input type='number' name='input_10[]' id='input_6_10_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_6_10_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_10[]' id='input_6_10_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_6_10_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_10[]' id='input_6_10_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_6_10_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_6_12\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_12'>Names of individuals involved<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_6_12' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_13\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_13'>Organism\/ Toxin Involved<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_6_13' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_14\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_14'>Biosafety Level<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_6_14' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_6_16\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Does this exposure or release event involve recombinant biological materials?<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_16'><li class='gchoice gchoice_6_16_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.1' type='checkbox'  value='Recombinant'  id='choice_6_16_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_16_1' id='label_6_16_1' class='gform-field-label gform-field-label--type-inline'>Recombinant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_16_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.2' type='checkbox'  value='Non-Recombinant'  id='choice_6_16_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_16_2' id='label_6_16_2' class='gform-field-label gform-field-label--type-inline'>Non-Recombinant<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_16_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_16.3' type='checkbox'  value='Unsure'  id='choice_6_16_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_16_3' id='label_6_16_3' class='gform-field-label gform-field-label--type-inline'>Unsure<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_17\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_17'>If recombinant, what genes were introduced into the organism? (Include toxins, antibiotic-resistant genes, or changes that may affect risks and treatment)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_6_17' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_18\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_18'>Provide a brief description of the exposure\/ release event.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_18' id='input_6_18' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_19\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below 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