Human Gene Transfer Closure Notification Human Gene Transfer Closure Notification Principal Investigator: * Degree: M.D. Ph.D. Other:Other: Department/Division: * Email Address: * Office Address: * Office Address: Office Address: Office Address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Office Phone Number * Lab Address: * Lab Address: Lab Address: Lab Address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Lab Phone Number: * List any personnel and students approved by the IBC that will remain to work on these experiments during the transition. Name: Title: Lab Address: Lab Address: Lab Address: Lab Address: City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Number plus1 Add personnel minus1 Remove personnel Project Title: IBC Registration Number (located on approval letter): Building: 0 - Unknown1 - PARK2 - VOICE3 - DGH4 - KH5 - GTB6 - ST7 - LS8 - AEB9 - JWB10 - PHYS11 - WBB12 - FASB13 - LCB14 - JTB17 - PAB19 - INSCC25 - BEH S26 - SW27 - S BEH28 - MCD29 - FLD H30 - PLAZA32 - STAD33 - CFC35 - UMFA36 - FMAB37 - ARCH38 - ART39 - SCULPT40 - SSB41 - NWPG43 - NS44 - 4445 - CTIHB49 - LNCO51 - SILL52 - ALUMNI53 - UNION56 - CME57 - HEDCO58 - MPL59 - MSRL60 - ESB61 - MCE62 - WEB63 - WEB64 - MEB65 - MBH66 - PMT67 - U CAMPSTOR69 - CPG70 - LAW71 - SAEC72 - BLDG 7273 - BLDG 7374 - BU C77 - CRCC79 - SFEBB82 - ASB83 - JFB84 - BIOL85 - HEB86 - M LIB87 - TBBC90 - JHC91 - HPR E92 - HPR N93 - HPRNAT94 - HPR W95 - HPR SW96 - HPR SE97 - DGC98 - KBAC99 - hbf103 - RR105 - ANNEX108 - GLF SH109 - DFSS110 - SLC111 -112 - MHC116 - CSBB119 - BRIDGE124 - BD 124126 - BTS130 - CAULD149 - B 149151 - SMBB170 - FAW171 - BIKE179 - EBC180 - SPACE182 - B 182184 - S PROJ190 - INSTPK197 - ROSEN198 - EH200 - UKIDS205 - GETC206 - GETC210 - SCEFC212 - SEFH213 - LIB SG214 - BD 214215 - SHOP216 - SKI BLDG219 - DUGOUT255 - BD 255258 - BD 258260 - BD 260263 - BD 263274 - BD 274301 - SAFETY302 - ECP303 - HTW304 - Bd 304305 - PP SER306 - BLG GR308 - RECYCL309 - MOTOR317 - GAS ST320 - RB TRA323 - RB GRE324 - EQUIP325 - B 325327 - PPO GH329 - GH ARB331 - DEEPWELL1332 - PUMP 2334 - PUMP 4335 - PUMP 5336 - PUMP 6337 - PUMP 7338 - PUMP 8341 - ELEC S342 - ESS-MC343 - ESS-RP347 - STMGEN348 - STG HU349 - TRANSF350 - VRTUSB361 - PS 5362 - PS 2363 - PS 1364 - PS 3365 - PS 4366 - EPCOS369 - APS370 - CHCTR372 - MEK373 - PCPT374 - PCMC379 - BD 379381 - BUS 1382 - BUS 2383 - BUS 3384 - BUS 4385 - BUS 5386 - BUS 6387 - BUS 7388 - BUS 8389 - BUS 9390 - BUS 10391 - BUS 11392 - BUS 12393 - BUS 13394 - BIOL S395 - BUS 15396 - BUS 16439 - BD 439440 - BD 440441 - BD 441443 - BD 443444 - BD 444445 - BD 445446 - BD 446447 - BD 447448 - BD 448458 - ROCS471 - BD 471472 - BD 472473 - BD 473474 - BD 474475 - BD 475476 - BD 476477 - BD 477478 - BD 478479 - BD 479482 -483 - B 483484 - B 484485 - B 485489 - UBSB490 - BD 490492 - DUG SE500 - CVRTI512 - RAB515 - BD 515516 - BD 516521 - SOM522 - WPAV523 - MEC524 - MCPT525 - U HOSP526 - HOSPPL527 - UHPT529 - ECCP530 - WINTRO531 - MREB532 - WPGP533 - EIHG535 - DDB540 - HSCPT543 - HEAT M550 - CNC555 - HCI556 - HCH560 - HSNET561 - HNPTH565 - EEJMRB570 - BPRB575 - EHSEB581 - SRB582 - SK H585 - RB LAB586 - RB ADM587 - CMC588 - CNB589 - E LIB590 - RWMF601 - FD 601602 - FD 602603 - FD 603604 - PLEC605 - FD 605606 - FD 606607 - FD 607608 - FD 608609 - FD 609610 - FD 610611 - FD KEN612 - FD 612613 - FD 613614 - FD 614615 - FD 615616 - FD 616617 - FD 617618 - FD 618619 - FD 619620 - FD 620621 - FD 621622 - FDAIRC623 - FD 623624 - FD 624625 - FD 625626 - FD 626627 - FD 627631 - FD 631632 - FD 632634 - FD 634636 - FD 636638 - FD 638639 - FD 639640 - FD 640643 - FD 643644 - FD 644645 - FD 645648 - FD 648649 - FD 649650 - FD 650652 - LEAP HOUSE653 - FD 653655 - FD 655656 - FD 656657 - FD 657658 - FD 658659 - FD 659660 - FD 660661 - FD 661662 - FD 662663 - FD 663664 - FD 664665 - FD 665666 - FD 666670 - FD 670676 - FD 676685 - MHCB701 - BD 701702 - BD 702706 - BD 706707 - BD 707720 - BD 720721 - BD 721722 - BD 722723 - BD 723724 - BD 724725 - BD 725726 - BD 726727 - BD 727728 - BD 728729 - BD 729730 - BD 730731 - BD 731732 - BD 732733 - BD 733734 - BD 734735 - BD 735736 - BD 736737 - BD 737738 - BD 738739 - BD 739740 - BD 740741 - BD 741742 - BD 742743 - BD 743744 - BD 744745 - BD 745746 - BD 746747 - BD 747748 - BD 748749 - BD 749750 - BD 750751 - BD 751752 - BD 752753 - BD 753754 - BD 754755 - BD 755756 - BD 756757 - BD 757758 - BD 758759 - BD 759760 - CC 760761 - BD 761762 - BD 762763 - BD 763764 - BD 764765 - BD 765766 - BD 766767 - BD 767768 - BD 768769 - BD 769770 - BD 770771 - BD 771772 - BD 772773 - BD 773774 - BD 774775 - CC 775801 - GUEST802 - CG 802803 - CG 803804 - CG 804806 - GH 806807 - GH 807810 - SP 810811 - SP 811812 - SP 812813 - SP 813814 - SP 814815 - H CTR820 - BP 820821 - BP 821822 - BP 822825 - SR 825826 - SR 826827 - SR 827828 - SR 828829 - SR 829830 - SR 830837 - ATMOS840 - UUSOD841 - UUSODPT845 - RBGAMP846 - ORANGE848 - SPROUT849 - CVC851 - UUOC852 - UUOCPT853 - DHPEB854 - 505 WA856 - 423 WA857 - 421 WA858 - 420 WA859 - 419 WA860 - 417 WA865 - 295 CH866 - 295 CH870 - 500 HUU872 - NHMU873 - 515 Colorow874 - 383 CO876 - 375 CH878 - 391 CH879 - 515 Colorow881 - UUNI884 - ARUP886 - 615 AR887 - 675 AR888 - 729 AR890 - 540 AR892 - 585 KO894 - 610 BH896 - 650 KO901 - BD 901902 - BD 902903 - BD 903904 - BdD904908 - BD 908915 - BD 915916 - BD 916917 -918 - BD 918942 - BD 942944 - BD 944945 - BD 945946 - BD 946947 -952 - BD 952954 - BD 9543000 - B 30003012 - B 30123030 - B 30303031 -3100 - MVHC3101 -3105 -3110 - FS33113 - FS43114 -3270 -3401 -3402 -3404 -3439 -3440 -3441 -3442 -3448 - B 34483454 - B 34543458 - B 34583459 -3460 - B 34603464 - B 34643465 - B 34653466 - B 34663467 - B 34673475 - B 34753476 - B 34763477 - B 34773478 -3486 - B 34863487 - One Sandy Center3491 - B 34913502 - B 35023512 - B 35123516 - B 35163521 - BCFAC3523 - B 35233524 -3525 -3529 - ATC3533 - B 35333541 - B 35413546 -3551 - B 35513553 - B 35533554 - B 35543555 - B 35553556 - B 35563557 - B 35573559 - BD 35593561 - BD 35613562 - BD 35623563 - BD 35633564 - BD 35643565 - BD 35653566 - BD 35663567 - BD 35673568 - BD 35683569 - BD 35693570 - BD 35703571 - BD 35713572 - BD 35723573 - BD 35733574 - BD 35743576 - B 35763577 - B 35773579 - B 35793580 - B 35803582 - B 35823586 - B 35863587 - B 35873589 - B 35893590 - B 35903591 - B 35913592 - B 35923593 - B 35933594 - B 35943601 - B 36013602 - B 36023604 - B 36043605 - B 36053607 - B 36073608 - B 36083611 - B 36113612 - B 36123614 - B 36143616 - B 36163617 - B 36173619 - B 36193621 - B 36213622 - B 36223625 -3650 - B 36513651 - B 36513652 -3653 - NEPHI3654 -3655 -3656 -3661 -3662 -3663 -3664 -3665 -3701 - B 37013702 - B 37023714 -3715 - B 37153716 -3717 -3720 - B 37203721 -3735 - B 37353736 - B 37363737 - B 37373738 - B 37383739 - B 37393760 - B 37603761 - B 37613762 - B 37623763 - B 37633764 - B 37643765 - B 37653766 - B 37663767 - B 37673768 - B 37683775 - B 37753851 - EHECVC3852 - EHECSH3853 - EHECCB3854 - EHECAR3855 - EHECAS3856 - EHECMSH3857 - EHECSC3862 - EHECSDA3863 - EHERS3864 - EHECDHEC3865 - EHECWS3866 - EHECSB3867 - EHEGC3868 - EHEMH4580 - Transmiter45814582900090019002995099609970 Room #: Study Closure Date: Are there still patients enrolled in this study? Yes No Have all doses of the study drug/agent been administered? Yes No Is the study still ongoing at other sites? Yes No What is the status of patient enrollment at those sites? Have there been any unexpected adverse events associated with the use of this study drug/agent? Yes No Were these reported to the: IBC - Date:IBC - Date: IRB - Date:IRB - Date: NIH - Date:NIH - Date: Is there still study drug/agent on site? Yes No Are there decontamination procedures in place for disposal of unused or remaining agent(s)? Yes No Where will the product/agent be disposed? Onsite Offsite Provide documentation of how it will be disposed: Where will it be disposed: How will it be disposed: Please attach the most recent report from the Data and Safety Monitoring Board (DSMB). Drop a file here or click to upload Choose File Maximum file size: 5MB By checking this box I certify that all herein provided information, and any subsequent information submitted in connection with this application, is accurate and complete. Principal Investigator Signature * signature keyboard Clear Date * reCAPTCHA Δ
