SSBA Reporting Forms: Registered Facility Report Temporary Handling or Disposal of an SSBA

Use this form if you are a Registered Facility undertaking a Temporary Handling or Disposal of a Known SSBA that you are Not Registered to handle.

A temporary handling must only be for seven (7) working days or less.

Page last updated: 13 May 2014

Release Date: April 2014

Please complete this form if you are Registered Facility undertaking a Temporary Handling or Disposal of a known SSBA that you are Not Registerd to handle.

A temporary handling must only be for seven (7) working days or less.

Introduction

The National Health Security Act 2007 allows entities to handle known1 SSBAs on a temporary basis (seven working days or less). Following the handling, the entity must dispose of the SSBA, (through complete transfer or destruction) and report the disposal to the Department of Health (Health). During this time, the entity must be comply with the requirements under Part 11 of the SSBA Standards.

If you are required to continue handling the SSBA for longer than the prescribed seven working days (for example, to complete testing on the SSBA), you must apply to Health for an extension prior to the end of the temporary handling period. To apply for an extension, complete the Application for Extension section in this form. If this request is granted you must dispose of the SSBA at the end of the extended time period and report the disposal to Health within two business days after it occurs.

If an extension is not requested, or is not granted, and you intend to continue to handle the SSBA, you must apply to register to handle the SSBA using the Start to Handle a New SSBA form.

Note: These new requirements do not affect the handling of suspected SSBAs including an entity receiving a positive confirmatory test result from a previously suspected SSBA. These agents must continue to be handled under Division 4A of the NHS Act and Parts 9 and 9A of the SSBA Standards.

Providing information to Health

The information you provide to Health is mandated by the National Health Security Act 2007 and will be included on the National Register of Security Sensitive Biological Agents.

It is important to answer all questions and to provide accurate information. If the information you provide is incorrect or incomplete, Health may require you to provide additional information. This may cause delays.

Privacy

Personal information supplied to Health is handled according to the requirements of the Privacy Act 1988.

Application Authorisation

Please ensure that the person completing this form holds the appropriate authority to submit this application on the behalf of the entity or facility.

Instructions on completing this form

This document allows electronic entry of information into the required fields. It is recommended that, where possible, this form should be completed on a computer and a copy printed, signed and sent to Health.

All questions are mandatory unless otherwise stated and must be completed. If the space provided in each field is not sufficient to complete your answer, please include any additional information in an attachment with the information clearly marked as to which question it relates to.

Please ensure you retain a copy of this completed form as Health is unable to provide copies of submitted documents.

top of page

Lodgement

To lodge this form via post you will need to use an opaque envelope and post using Australia Post’s Registered Mail service. You are considered to have submitted the report at the date and time shown on the registered post receipt.

Please do not email or fax forms to Health as these cannot be accepted.

Please submit all postal applications to:

The Director
Health Emergency Countermeasures Section
Department of Health
MDP 140, GPO Box 9848
Canberra ACT 2601

Once Health has received the form, you will be provided with a confirmation of receipt by email to the contact officer listed for the facility.

Further Information

Please use your facility reference number to refer to any matters relating to your facility.

If you have any queries about this form please contact the SSBA Regulatory Scheme:

Telephone: (02) 6289 7477
Email: SSBA

top of page

Part 1: Entity and Facility Details

If you have a facility registration number, please complete this section and move to Part 3.

Reference Number.
Facility number (if known)
Entity name
Facility name

Part 2: Entity and Facility Details

If you do not have access to your facility reference number please complete the details below.

Section 2.1: Entity Details
Full name of entity (legal name)
Entity trading name (if different)
ABN
ACN (if applicable)
Australian Registered Body Number (if applicable)
Section 2.2: Entity Physical Address
Address 1
Address 2
Suburb/City
State
Postcode
Section 2.3: Entity Postal Address (if different from above)
Address 1
Address 2
Suburb/City
State
Postcode
Section 2.4: Entity Contact Details
Telephone number
Email address
 
Section 2.5: Facility Details
Facility name
Room number/s (if applicable)
Level/floor (if applicable)
Building name (if applicable)
Section 2.6: Facility Physical Address
Address 1
Address 2
Suburb/City
State
Postcode
Section 2.7: Facility Postal Address (if different from above)
Address 1
Address 2
Suburb/City
State
Postcode
Section 2.8: Contact Details of the Responsible Officer
Title (e.g. Dr, Mr, Ms etc)
First name
Middle name
Last name
Telephone number
Facsimile number
Email address
top of page

Part 3: SSBA Handling Details

Please complete the details for the SSBA

Section 3.1: SSBA Details
Suspected SSBA
Specific strain, serotype or toxin subunit (if applicable)
Section 3.2: Origin of the SSBA
Received from
Received date
Reason for receipt
E.g.: diagnostics, antibiotic sensitivity testing etc.
Section 3.3: Handling of the SSBA
What have you done/intend to do with the SSBA?

Handle
If you intend to continue to handle this SSBA you must complete an Start to Handle a New SSBA report within two business days of the end of the temporary handling period.
To apply for an extension of the temporary handling period, complete the question below and Part 3.4.
If you intend to register, please move to Part 4.

Transfer
Please note: you may both transfer a sample of the SSBA and destroy the remaining SSBA as part of the disposal process

Destroy

Do you need to retain the SSBA for longer than seven business days prior to disposal (transfer or destruction)?

Yes
Please move to section 3.4

No
Please move to next applicable section 3.5 or 3.6

Section 3.4: Application for Extension - Retain the SSBA for Longer than Seven Business Days
Why do you need to retain the SSBA for longer than seven business days?

What date do you intend to dispose of (transfer or destroy) the SSBA?

How do you intend to dispose of the SSBA?

The SSBA must be disposed of by complete transfer or destruction of the agent at the end of the handling period. SSBAs may be disposed of by both transfer (eg to a reference laboratory) and destruction (of any remaining samples).

Transfer

Destroy

Please note that if an extension is granted you will need to report the complete transfer or destruction of the SSBA within two business days after the action has occurred or the end of the extended handling period, whichever comes first.

Comments (if applicable)
Section 3.5: Transfer of the SSBA
Have you transferred your entire holding of this SSBA?

Yes
Please complete remaining questions in this section

No
Please complete the remaining questions in this section and section 3.6 explaining what you have done with the remainder of this SSBA

Date of transfer
Receiving organisation name
Receiving organisation address
Receiving organisation contact name
Receiving organisation contact telephone number

Arrival date at receiving facility
(if known)

Was the transfer successful2 according to the SSBA standards?

Yes
Move to Section 3.6 or Part 4

No
Please provide description in field below

Lost in Transit or Unsuccessful Transfer

Please provide a brief description of what happened

Mandatory reporting to law enforcement is required under the NHS Act. For further information please see Guideline 05 - Reporting to Law Enforcement or the National Security Hotline, available through our website – www.health.gov.au/ssba

Section 3.6: Destruction of the SSBA
Have you destroyed your entire holding of this SSBA?

Yes
Please complete remaining questions in this section

No
Please complete the remaining questions in this section and section 3.5 explaining what you have done with the remainder of this SSBA

Date of destruction
Method of destruction
Comments (if applicable)
top of page

Part 4: Signature

The information collected on this form may be used by the Department of Health to decide whether to vary the National Register of Security Sensitive Biological Agents (National Register). If a decision is made to vary the National Register, the information contained on this form, including personal information, will be recorded on the National Register by the Department.

The information collected on this form is authorised under the National Health Security Act 2007 and National Health Security Regulations 2008. Information collected on this form may be disclosed by Health to the Australian Security Intelligence Organisation, law enforcement agencies such as the Australian Federal Police and State and Territory police forces, other agencies responsible for responding to emergencies and other specified persons. The Department is unlikely to disclose personal information to overseas recipients.

The Department has an Australian Privacy Principles (APP) privacy policy which you can read. You can obtain a copy of the APP privacy policy by contacting the Department by telephone on (02) 6289 1555, freecall 1800 020 103 or by using the online enquiries form.

The National Register is hosted and maintained by the Attorney-General’s Department.

I declare that:

  • I am duly authorised to sign this declaration on behalf of the entity associated with this facility;
  • The information supplied on this form and any attachment is true and correct; and
  • This entity is compliant with the SSBA Standards currently in force.
Signature
Date
Full name (Please print)
Position title
Contact telephone number
Contact e-mail address

  1. A known SSBA for the purposes of temporary handling requirements is one that was confirmed by laboratory testing before being transferred into your facility.
  2. A successful transfer is defined under the SSBA Standards as verification that the complete shipment of the SSBA (quantity and type), as covered by the shipment documents, has been received and that there is no evidence of tampering to the shipping container.
top of page