SSBA Reporting Forms: Application for Extension

Use this form to apply for an extension when you are required to handle an SSBA for longer than prescribed timeframes. Please note an extention is not required when waiting for the results of confirmatory testing.

Page last updated: 12 May 2014

Release Date: April 2014

Introduction

The National Health Security Act 2007 (NHS Act) mandates that entities handling SSBAs report to the Department of Health (Health). 

An entity must only retain and handle an SSBA for which it is not registered for the following prescribed handling periods:

Entities handling a known1 SSBA under the Temporary Handing provisions - 7 working days

Entities handling a previously suspected SSBA that has been confirmed as an SSBA by in-house or external testing - 2 working days

Entities may be required to retain SSBAs for longer than the prescribed handling period, for example, under the National Pathology Accreditation Advisory Council (NPAAC) guideline on Requirements for the Retention of Laboratory Records and Diagnostic Material. If there is a requirement to retain the SSBA for longer than the prescribed handling period, you must request an extension to continue handling the SSBA. If this request is granted you must then dispose2 of the SSBA following the extended handling period and report the disposal to Health within two business days of the disposal occurring, or register to handle the SSBA.

Please do Not complete this form if you waiting for confirmatory testing results for a suspected SSBA. You must notify Health of the transfer of the Suspected SSBA for, and the outcomes of, confirmatory testing using the appropriate Report for Suspected SSBAs and Confirmatory Testing Results.

You must complete a separate form each time you wish to request an extension to the prescribed handling period.

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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 SSBAs.

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 provided 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 behalf of the entity or facility. For non-registered facilities the person authorised to make this report may be a person who senior management determines has responsibility for overseeing work related to SSBA material, eg Laboratory Managers.

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 marked with an * are mandatory and must be completed. Other fields are to be completed only if the information has changed. 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.

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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

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Part 1: Registration or Reference Number

Facility registration number or reference number
Entity name
Facility name

Part 2: SSBA Details

Please provide the details of the report type.

SSBA Details
SSBA

 

Sample identification number

 

Specific strain, serotype or toxin subunit (if applicable)

 

What date did your receive the SSBA

 

Part 3: Application to Retain the SSBA for Longer than the Prescribed Period

Please provide details regarding the requirements for retaining the SSBA for longer than the prescribed handling period.

Application to Retain the SSBA or Suspected SSBA
Why do you need to retain the SSBA for longer than the prescribed period?
What date do you intend to dispose3 of the SSBA?

What do you intend to do with the SSBA after this period?

Please note that if an extension is granted you must report what actions are taken after the extension period. This report must be submitted to Health within two business days after the action has occurred.

Comments (if applicable)
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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 is one that has been confirmed as an SSBA prior to being transferred to the reporting facility.
  2. Disposal is the complete transfer or destruction of the SSBA.
  3. Dispose means the complete transfer or destruction of all holding of SSBA.
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