Form A-CL3 - Contact Information

PDF (29 kb)

The information provided on this form will help establish the lead agency, either the Canadian Food Inspection Agency (CFIA) and/or the Public Health Agency of Canada (PHAC). The lead agency will be determined based on program intent and pathogen list.

Facility:

Room(s):

• Postal Address:
• Tel:
• Fax:
• E-mail:
• Website:

Contact Information:

1) Facility Supervisor (main contact)

• Name:
• Title:
• Department:
• Address:
• Phone number:
• Fax number:
• E-mail:
• Language preference: English / Français
• Other comments:

Signature: Date:

2) Biosafety Officer (or equivalent)

• Name:
• Title:
• Department:
• Address:
• Phone number:
• Fax number:
• E-mail:
• Language preference: English / Français
• Other comments:

Signature: Date:

---

Type of Facility:

• Government (federal)
• Government (provincial)
• University
• Hospital
• Private
• Other

Modifications:

• Upgrading Existing Facility
• Renovations
• New Construction Site
• Other

Program Intent

(brief description of the type of work [research, diagnostic, production] and list procedures with the potential to generate aerosols):

Scale/Volume:

• Laboratory
• Large Scale

Comments:

Other

Pathogens:

• Affecting Humans - Yes    No
• Affecting Animals/Fish - Yes    No

Comments:

List of Pathogens

(species and subtypes where applicable):

Use of Animals:

Yes    No

Species and quantity:

---

Internal Use Only

Lead agency:  CFIA  PHAC  CFIA & PHAC  CFIA only  PHAC only

Lead Role Rationale