Form 20-2-2

Safety Office←Person in charge of experiment

Genetically Modified Organisms Carry In/Out Notification Form
To: The Director, Japan Synchrotron Radiation Research Institute

Date of submission: March 10, 2016

1. Submit this form at least 10 days prior(Person in charge of experiment)
to the day of carry in/out.
Name of the organization
2. Attach the document providing
Japan Synchrotron Radiation Research Instituteinformation based on the Law Concerning
Department and title
the Conservation and Sustainable Use ofXX Department, Researcher
Biological Diversity through Regulations
Nameon the Use of Living Modified Organisms.
Saburo XXXX
3. The person in charge of the experimentmust notify the Safety Office at thecompletion of carry in/out.
I apply for the safety control of a genetic recombination experiment as follows.
Notification
Acceptance number1)
Carry in or carryout?2)
Scheduled date ofcarry in/out

Person in charge ofcarry in/out3)

Organization andperson in charge ofthe other party4)

Provision ofinformation5)01-01
 in ■ out
March 19, 2016
Name of organization
Japan Synchrotron Radiation Research InstituteDepartment and nameXX Department, Saburo XXXX
Address (Postal code)
1-1-1 Koto, Mikazuki-cho, Sayo-gun, Hyogo
Phone: 0791-**-**** (PHS ****)
Fax: 0791-**-****
E-mail: saburo@*******.**.jp
Name of organization
XXX University XXX Laboratory
Department and name
XXX Department, Hashio XXX
Address (Postal code)*-*-* **, ****, ***, Tokyo
Phone: 03-***-****
Fax: 03-***-****
E-mail: hashio@********.**.jp■ Attached to this document
 Others (Attach document providing information based on theLaw Concerning the Conservation and Sustainable Useof Biological Diversity through Regulations on the Useof Living Modified Organisms.
The provided information involves the following:(1) Notice of Type 2 Use of Living Modified Organisms.
(2) Name of host and modified nucleic acid(3) Name and address(4) Other necessary items)- 1 -Form 20-2-2

Genetically modifiedorganisms that will
be carried in/out6)

Safety Office←Person in charge of experiment

Name of host or parentorganism

Introduced trait

Containment level

AmountNotes

Omit if you are attaching a document providing information. If you are not attaching adocument providing information, state the reason in the “Provision of information” section,and describe the details about the genetically modified organisms that will be carried in/out.
PackagingTransportation
methodForm of transport etc. Scheduled carry insite at Japan
Synchrotron
Radiation ResearchInstitute

Place the sample in a 1.5-mL tube, wrap in shock-absorbing
material, and pack in a Styrofoam container.
 Mail ■ Vendor (courier)  Private vehicle

Confirmation of carry in/out of genetically modified organisms7)

Confirmation of carry out of genetically modified organismsIn

carrying
geneticallymodifiedorganismResearchinto Japan
Synchrotron Radiation Research Institute confirm that theDirector,
Japan
Synchrotron
Radiation
Institute
To:Whenorganization from which the genetically modified organism is carried out , has agreed to provide such organism to japan
Synchrotron
Research Institute.
This requirement
dose not apply
if theisgeneticallyorganism
carriedour
Regardingtheradiation
above-mentioned
geneticallymodified organism
which
scheduledmodified
to be carriedoutisfromin directly bytoa bevendor.
organization
carried into Japan Synchrotron Radiation Research Institute,
there is no problem in carrying it to Japan Synchrotron Radiation Research Institute.
Year:
Month: Day:
Name of the organization
 Safety Supervisor /  Director of Safety Committee
Name

Confirmation of carry in of genetically modified organisms
To: Director, Japan Synchrotron Radiation Research Institute
When carrying
genetically modifiedgeneticallyorganism outmodified
from Japanorganism
Synchrotron
Radiation
Research Institute,confirmout
thatfrom
theRegarding
the above-mentioned
which
is scheduled
to be carriedorganization
into which
the geneticallymodifiedorganism
carriedhas agreed
acceptthe organism.all the necessary
Synchrotron
Radiation
ResearchInstitutetois becarried
into toour
organization,■ Japanproceduresfortheuseoftherelevant
geneticallymodifiedorganism
have
been
finalized, and thus there is noOut
problem with carrying it into our organization.
Year:2016 Month:3 Day:9
Name of the organization XXX University XXX Laboratory Safety Supervisor / ■ Director of Safety Committee
NameXXXX* Completed by Safety Office
Reception
YYYY/MM/DD
date

Confirmation seal ofcarry in/out

Confirmation bySafety Supervisor* Notes
1) “Acceptance Number” that was issued by the Safety Office when the Application for Approval of Genetic Engineering
Experiment was submitted.
- 2 -Form 20-2-2Safety Office←Person in charge of experiment2) Check either in or out. Note that genetically modified organisms may not be transferred or received if the experimental
subject using the relevant genetically modified organism is not approved at the organization of the person who will carryin/out the genetically modified organism.
3) State the person who will carry in/out the genetically modified organism.
4) State the person of the other party who will carry in/out the genetically modified organism.
5) Attach document providing information based on the Law Concerning the Conservation and Sustainable Use of biological
Diversity through Regulations on the Use of Living Modified Organisms to this form. If that document is not attached, state
the reason for not attaching the document.
6) If the document providing information based on the Law Concerning the Conservation and Sustainable Use of biological
Diversity through Regulations on the Use of Living Modified Organisms is not attached to this form, state the information
regarding the genetically modified organism etc.
This section can be left blank if the document providing information is attached.
7) To confirm whether the carry out/in of the relevant genetically modified organism is approved at the organization that isscheduled to carry in/out the genetically modified organism, confirmation by the safety supervisor or the director of thesafety committee of the relevant organization should be indicated. If the genetically modified organism is carried in directly
by a vendor, this requirement is not applicable.
8) This form should be submitted at least 10 days prior to the day of carry in/out. The person in charge of the experiment must
notify the Safety Office at the completion of carry in/out.

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