SSBA Reporting Forms: Initial Registration

Use this form if you wish to handle SSBAs. You must register within two business days of starting to handle the SSBA/s.

Page last updated: 24 July 2014

SSBA Reporting Forms List

Release Date: July 2014

Introduction

If you handle security sensitive biological agents (SSBAs), you must register with the Department of Health (Health). You are required to submit your initial registration application within two business days of starting to handle an SSBA. This application must be provided in hard copy to Health using this form.

Each facility must complete a separate initial registration form to register with Health.

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 will comply with 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.

Instructions on preparing this notification

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 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.

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: Entity Details

Please complete the details for the entity.

Entity Details
Full name of entity (legal name)

Entity trading name (if different)

ABN
ACN (if applicable)
Australian Registered Body Number (if applicable)

Physical Address
Address 1
Address 2
Suburb/City
State
Postcode
Postal Address (if different from above)
Address 1
Address 2
Suburb/City
State
Postcode
Contact Details
Telephone number
Facsimile
Email (if generic email address is available)
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Part 2: Facility Details

Please provide the details for the facility associated with the entity listed above. Please note that each facility is required to complete a separate Initial Registration form.

Facility Details
Facility name

Room number/s (if applicable)

Floor/level (if applicable)
Building name (if applicable)
Physical Address
Address 1
Address 2
Suburb/City
State
Postcode
Postal Address (if different from above)
Address 1
Address 2
Suburb/City
State
Postcode
Contact Details
Email (if generic email address is available)
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Part 3: Linked Storage Facility (Tier 2 SSBAs Only)

Please provide the details of the facility's linked storage unit.

Linked Storage Facility Details 1
Storage facility name

Is this storage facility located within the same building? Note: the storage facility must be within the same building as the registered facility and preferably on the same floor.

Yes - please complete questions below

No - please contact Health

Location of storage facility within the building (e.g. room number/floor/building name)
Has this storage facility been included in the facility's risk assessment and management plans?

Yes - please complete questions below

No - please contact Health

Is the storage unit fixed and non-transportable?

Yes - please complete questions below

No - please contact Health

Linked Storage Facility Details 2
Storage facility name

Is this storage facility located within the same building? Note: the storage facility must be within the same building as the registered facility and preferably on the same floor.

Yes - please complete questions below

No - please contact Health

Location of storage facility within the building (e.g. room number/floor/building name)
Has this storage facility been included in the facility's risk assessment and management plans?

Yes - please complete questions below

No - please contact Health

Is the storage unit fixed and non-transportable?

Yes - please complete questions below

No - please contact Health

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Part 4: Responsible Officers

Please provide the details for one Responsible Officer and one Deputy Responsible Officer.

Responsible Officer Name
Title (Dr, Mr, Ms etc)

First Name

Middle Name
Last Name

Contact Details
Business telephone number
Mobile or emergency telephone number
Facsimile (if applicable)
Email
Responsible Officer Postal Address (if different from the facility)
Address 1
Address 2
Suburb/City
Postcode
Deputy Responsible Officer Name
Title (Dr, Mr, Ms etc)
First Name
Middle Name
Last Name
Contact Details
Business telephone number
Mobile or emergency telephone number
Facsimile (if applicable)
Email
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Part 5: SSBA Details

Please complete the table below for each SSBA that this facility handles. The National Health Security Act 2007 defines handling as receiving, holding, using or storing SSBAs.

Section 1 - SSBA Details (SSBA 1)
Name of SSBA

Select SSBA

Specific strain, serotype or toxin subunit (if applicable)

Is the facility currently handling this SSBA?

Yes - Start date of handling:

No - please complete question below

If no, proposed start date of handling this SSBA

Is this SSBA only handled and stored within the registered facility?

Yes - please move to handling purpose section

No - please complete question below

Is this SSBA stored in this facility's linked storage unit?

Yes - please provide details:
and move to handling purpose section below

No - please complete question below

Is this SSBA stored in another registered facility?

Yes - registration number:

No - please contact Health if you have answer NO to all questions

Handling Purpose 1

Purpose for handling this SSBA

Please note: If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose (if different from handling start date)

Handling Purpose 2

Purpose for handling this SSBA (if applicable)

Please note:  If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose (if different from handling start date)

Handling Purpose 3

Purpose for handling this SSBA (if applicable)

Please note: If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose (if different from handling start date)

If you are handling the SSBA for research purposes please answer the following questions. If you have multiple, independent research projects you will need to separately complete the questions below for each project (you may photocopy this page as required). All questions must be answered with sufficient information as indicated, please do not leave any gaps if necessary indicate not applicable.

Section 2 – Handling an SSBA for Research purposes (SSBA 1)
Project title

Principle Researcher(s)

Briefly describe the research project and anticipated outcomes or application of the research (100 words)

Please indicate which committees oversee this research (e.g. Institutional Biosafety Committee, Ethics Committees etc)

Please indicate if the research is being undertaken in collaboration with other organisation domestically or internationally
Please provide a specific list of previous (past 5 years) and current funding for this research project

Please provide publication citations from the principal investigators (relevant to the work if it is a long-term project, or past 5 year’s citations from research team, including collaborators, if new work).

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Section 1 - SSBA Details (SSBA 2)
Name of SSBA

Select SSBA

Specific strain, serotype or toxin subunit (if applicable)

Is the facility currently handling this SSBA?

Yes - Start date of handling:

No - please complete question below

If no, proposed start date of handling this SSBA

Is this SSBA only handled and stored within the registered facility?

Yes - please move to handling purpose section

No - please complete question below

Is this SSBA stored in this facility's linked storage unit?

Yes - please provide details:
and move to handling purpose section below

No - please complete question below

Is this SSBA stored in another registered facility?

Yes - registration number:

No - please contact Health if you have answer NO to all questions

Handling Purpose 1

Purpose for handling this SSBA

Please note: If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose
(if different from handling start date)

Handling Purpose 2

Purpose for handling this SSBA
(if applicable)

Please note: If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose
(if different from handling start date)

Handling Purpose 3

Purpose for handling this SSBA
(if applicable)

Please note: If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose
(if different from handling start date)

If you are handling the SSBA for research purposes please answer the following questions. If you have multiple, independent research projects you will need to separately complete the questions below for each project (you may photocopy this page as required). All questions must be answered with sufficient information as indicated, please do not leave any gaps if necessary indicate not applicable.

Section 2 – Handling an SSBA for Research purposes (SSBA 2)
Project title

Principle Researcher(s)

Briefly describe the research project and anticipated outcomes or application of the research (100 words)

Please indicate which committees oversee this research (e.g. Institutional Biosafety Committee, Ethics Committees etc)

Please indicate if the research is being undertaken in collaboration with other organisation domestically or internationally
Please provide a specific list of previous (past 5 years) and current funding for this research project

Please provide publication citations from the principal investigators (relevant to the work if it is a long-term project, or past 5 year’s citations from research team, including collaborators, if new work).

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Section 1 - SSBA Details (SSBA 3)
Name of SSBA

Select SSBA

Specific strain, serotype or toxin subunit (if applicable)

Is the facility currently handling this SSBA?

Yes - Start date of handling:

No - please complete question below

If no, proposed start date of handling this SSBA

Is this SSBA only handled and stored within the registered facility?

Yes - please move to handling purpose section

No - please complete question below

Is this SSBA stored in this facility's linked storage unit?

Yes - please provide details:
and move to handling purpose section below

No - please complete question below

Is this SSBA stored in another registered facility?

Yes - registration number:

No - please contact Health if you have answer NO to all questions

Handling Purpose 1

Purpose for handling this SSBA

Please note: If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose
(if different from handling start date)

Handling Purpose 2

Purpose for handling this SSBA
(if applicable)

Please note: If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose
(if different from handling start date)

Handling Purpose 3

Purpose for handling this SSBA
(if applicable)

Please note: If you are handling the SSBA for research purposes you will need to complete Section 2 for this SSBA.

Start date for this purpose
(if different from handling start date)

If you are handling the SSBA for research purposes please answer the following questions. If you have multiple, independent research projects you will need to separately complete the questions below for each project (you may photocopy this page as required). All questions must be answered with sufficient information as indicated, please do not leave any gaps if necessary indicate not applicable.

Section 2 – Handling an SSBA for Research purposes (SSBA 3)
Project title

Principle Researcher(s)

Briefly describe the research project and anticipated outcomes or application of the research (100 words)

Please indicate which committees oversee this research (e.g. Institutional Biosafety Committee, Ethics Committees etc)

Please indicate if the research is being undertaken in collaboration with other organisation domestically or internationally
Please provide a specific list of previous (past 5 years) and current funding for this research project

Please provide publication citations from the principal investigators (relevant to the work if it is a long-term project, or past 5 year’s citations from research team, including collaborators, if new work).

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Part 6: Privacy Collection Notice

The information collected on this form may be used by 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 Health.

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. Health is unlikely to disclose personal information to overseas recipients.

Health has an Australian Privacy Principles (APP) privacy policy which you can read. You can obtain a copy of the APP privacy policy by contacting Health 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
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