Form20-1
SafetySupervisor

JASRI Safety Office

Person in charge of managing experiments

Confirmation bySafety Office

Project Leader
20YY, MM, DD

Receipt by theSafety Office

Application Form for Genetic Modification Experiment
Date of submission: June 1, 2016
To: The Director General, Japan Synchrotron Radiation Research Institute(Person in charge of experiment)1)
Name of the organization
XX University, Graduate School
Department and title
XX Department XX AssistantName (print and signature)
Koukido Hanako(Manager)2)

Name(Leave it blank if User is applying)

SealTo carry out the following genetic modification experiment, I hereby apply for approval of the genetic
recombination committee.
Receipt number3)Type of application4)
Title of experiment5)

Type of experiment6)

The purpose(2,1,.
1A,1(Do not write when submitting)
,ACE)
,, 2
C, , ,,.
E£ New,C,A.
£ Renewal (Previous receipt number . ,)Amendment (Previous receipt number Approval 03-10)
Examination of metabolism of XXX enzyme in XX deficient mice.
The title should concisely describe the purpose and a summary of the experiment
Microbiology experiment£ Large-scale cultivation experiment
Animal experiment (Animal inoculation £ Animal modification)£ Plant experiment (£ Plant inoculation £ Plant modification £ Fungus modification)
The dynamics of XXX enzyme will be examined by infecting mice with a virus that expresses
XXX enzyme due to a mutated XX gene.

The flow of the relevant genetic modification experiment should be stated.
Summary7),

Expected duration ofexperiment8)
Contact information of
the person in charge ofthe experiment

A,1,A,

1

C,, ,C, , ,1,

October **, 2016 to March 31, 2019
Address (Postal code)
1-1-1 Koto, Mikazuki-cho, Sayo-gun, Hyogo
Phone (ext./PHS) 07**—**—****(2***)
Fax: 07**-**-****
E-mail: hanako@********.**.jp- 1 -.

, 1,

Form20-1

Other contacts9))

JASRI Safety Office Person in charge of managing experiments
Organization and department of the person in charge of communications
XX University, Graduate School XX Faculty XX Lab Office
Name of the person in charge of communications
Last name First name
Address (Postal code)
1-1-1 Koto, Mikazuki-cho, Sayo-gun, Hyogo
Phone (ext./PHS) 07**—**—****(3***)
Fax: 07**-**-****
E-mail: shikaku@********.**.jp

Project Leader

Place of the experiment (place for animal keeping and raising)10) and place for storage of genetically modified organisms11))
Building

Experiment Hall

Room

P1

Containment measures
P1P
P2
P2A

P1A

P2PStorage£BL20B2 experimental hutch£BL28B2 optics hutch£BL40XU experimental hutch£BL20B2 animal operation room
£Mobile operation room
£BL38B1 experimental hutch£ＰＸＢＬ experimental hutch£

Experimental Animal
Facility
Medium-length Beamline
Facility(Experiment building)

Mouse room
Genetic experiment room
£Treatment room
£BL20B2 experimental hutch£BL20XU experimental hutch£Animal operation room£
£Room 101
£Room 201
£Room 202

Medium-length Beamline
Facility(Research building)

SACLA
Others(Write the name of thebuilding and room)£Room 204
£Room 212
£Room 213
Biochemistry lab 1 Room 208£Biochemistry lab 2 Room 209£Biochemistry lab 3 Room 210£Experimental hutch (EH3)£Biological sample prep. room£,.
.
( ,. 1, 2 1,,,C
1,,C ,1,.
,

2

1,2,, ,,, ,C,1, ,***** building …… room

Nucleic acid donor/Donor nucleic acid12)
Nucleic acid donor
Experimentclassification(Target gene)
Streptomyces lavendulae ##Class 1
strain: genus Streptomyces
bacteria of the family
Streptomycetaceae

Donor nucleic acid (type of nucleicacid)

Identification
Completed/Not completed

XX enzyme gene (cDNA)- 2 -Completed,

NoteForm20-1
Protostome:Schistosoma
japonicum. , 2 2 C

Mouse

JASRI Safety Office Person in charge of managing experiments
Class 2Glutathione S-transferase (cDNA)
Completed,,,,,,Class 1

XX enzyme gene (cDNA)

Completed

Class 1

tac promoter (genome DNA)

Completed

Class 1

lac promoter (genome DNA)

Completed

Bacteriophage T7

Class 2

T7 promoter (genome DNA)

Completed

E. coli of the familyEnterobacteriaceae

Class 1

Ampicillin-resistant gene(genome DNA)

Completed

Experimentclassification

VectorType(Expression regulatory gene)
E. coli of the familyEnterobacteriaceae
E. coli of the familyEnterobacteriaceae

Project Leader(Selectable marker gene)

Host/vector13)
HostNote

Microorganism/Animal/Plant

EK1Class 1

pUC119 (cloning vector for E. coli)
pGEX (vector for protein expression)

Microorganism

SD rats and fertilized eggs ofSD rats

Class 1

Not used

AnimalCharacteristics of animals,
plants, or cells that possess
genetically modifiedorganisms.14)

Insect cells will be used for cultured cells that will be infected with a geneticallymodified virus. The cultured cell line that will be used in the experiment will not growanywhere else than on the artificial medium. The gene inserted into the geneticallymodified virus will be expressed by infection. The infected cells will die due to virus
multiplication. The infected cells will not develop drug resistance.

Table of genetically modified
organisms and containment
measures.15)
Method of inactivation ofgenetically modified
organisms.16)
Note17)

as per attached
Inactivate by autoclaving (121, 20 minutes).
Grant-in-Aid for Scientific Research of Japan Synchrotron Radiation Research Institutewill not be used.
If public funding (such as Grant in Aid for Scientific Research of the Ministry of Education,Culture, Sports, Science and Technology) is received as Japan Synchrotron Radiation
Research Institute, indicate it accordingly.

- 3 -Form20-1

JASRI Safety Office

Person in charge of managing experiments

Project Leader

Notes1) For “Project Leader,” the information shall be given on a person who is directly manage a genetic recombination
experiment at SPring-8 and have experience for one year or more. However, a student should not be.
2) For “Person in charge of managing experiments,” the information shall be given on a person who is in charge ofadministration of this application.
JASRI, RIKEN, JAERI Staff >> Director
User >> Director of Users Office
A blank is sufficient in case it submits.
3) Since "Proposal number" is informed when Safety Office receives this application, leave a column blank. Proposal number
is required for all the documents for which you will apply in the future.
4) For “Type of Application,” select any items under which your application falls. In case Continuation or Changes, give theprevious proposal number.
5) For “Title,” mention a name that expresses the objective and an outline of a genetic recombinant experiment briefly.
6) For “Type,” select all items under which a genetic recombinant experiment falls.
7) For “Outline,” all living modified organisms involved in a genetic recombinant experiment and the categories ofcontainment measures to be taken during a genetic recombinant experiment shall be mentioned so as to show theirprocesses.
8) The experiment is valid for a maximum of three years from approved day.
9) For “Other contact,” if there is any other contact for administrative matters than Project Leader or Deputy Project Leader,give the information on the contact.
10) For “Laboratory ,Experiment area ,Experiment section (include the area of the breeding animals or culture of plants) ,”select all area under which a genetic recombinant experiment falls. If there is no appropriate column, indicate name offacility and room on proper column and attach the information those mentioned in below.
Names and positions of major facilities, equipment and apparatus;
In case an animal or a plant that has no relation with a genetic recombination experiment is bred or cultured in thelaboratory, the experiment section, the experiment area, the breeding section or the screened greenhouse, the state of thebreeding of the animal or the culture of the plant;
11 For “Facility of Storage,” select all area that storage living modified organisms in the process of a genetic recombination
experiment. If there is no appropriate column, indicate name of facility and room on proper column and attach theinformation about them.
12) For “Donor organism/Donor nucleic acid,” the following shall be mentioned about the donor organism and donor nucleic
acid of the living modified organism for Genetic recombination experiment every component elements (target genes,expression regulatory genes, drug-resistant genes and marker genes).
a. General name and taxonomical position (familia, genus, species, strain) of donor organism
b. General name and type (such as genomic nucleic acid, complementary deoxyribonucleic acid or synthesized nucleicacid) of donor nucleic acid.
c. Attach copy of nucleotide sequence information or an accession number to the nucleotide sequence database of, forexample, the Japan DNA Databank (only in the case of donor nucleic acid that is identified nucleic acid).
13) For “Recipient organism/Vector,” the following shall be mentioned about the recipient organism and vector of the living
modified organism for Genetic recombination experiment.
a. General name and taxonomical position (familia, genus, species, strain) of recipient organism
b. General name, code and short explanation about (ex. pUC119 cloning vector for E.coli)c For “Type,” select Microorganisms, Animals or Plants.
14) For “Characteristics of animal, plant or cell which retains living modified organisms,” in addition to items those mentioned
in below, characters expected to be newly given or already given to an animal, a plant or a cell which retains the living
modified organism for Genetic recombination experiment in comparison with animals, plants or cells which do not retain
the living modified organisms Genetic recombination experiment shall be mentioned.
a. Taxonomical position and experiment classification of animal, plant or cell which retains living modified organism;b. State of distribution in natural environment and environment in which living or growth is possible;c. Pathogenicity, production of harmful substances and other properties;
15) For “Combination Living Modified Organism and its Category of Containment Measures,” all donor organisms, donor
nucleic acids, vectors, recipient organisms and animals, plants or cells which retains living modified organism involved ina genetic recombination experiment and the categories of containment measures to be taken during the experiment shall bementioned so as to show processes of the experiment.
16) For “Measure for inactivating living modified organism,” about the containment measures to be taken during Genetic
recombinant experiment, mention a measure for inactivating waste products containing the living modified organism andapparatus and appliances to which the living modified organism sticks, and the effectiveness of the measure.
17) Provide a note when you have received a public grant (such as Grant-in-Aid for Scientific Research from the Ministry ofEducation, Culture, Sports, Science and Technology) affiliated with JASRI, when the research proposal is for a position
paper of the Ministry of Education, Culture, Sports, Science and Technology, or when you have special comments.

- 4 -Form 20-1

Safety Office ← Manager ← Person in charge of experimentAttachment.

.

.

Table of genetically modified organisms and containment measures.
Nucleic acid donor
Donor nucleic acid.

.

VectorHost etc.

.

.

.

,.

Possessingorganisms
None

Containment Measure
Classification
P1NoteStreptomyces lavendulae## strain
Mouse
E. coliXX enzyme gene (cDNA)
XX enzyme gene (cDNA)
lac promoter (genome DNA)
Ampicillin-resistant gene

pUC119

JM109 derived from
E. coli K12 strain

Mouse
Bacteriophage T7
E. coliXX enzyme gene (cDNA)
T7 promoter (genome DNA)
Ampicillin-resistant genelac I (genome DNA)

pET

BL21 (DE3) derived
from E. coli B strain

None

P1

Level B1
Protein expression

E. colitac promoter (genome DNA)lac I (genome DNA)

pGEX

BL21 derived from
E. coli B strain

None

P1

Level B1
Protein expression

Schistosoma japonicum
Streptomyces lavendulae## strainGlutathione S-transferase(cDNA)
XX enzyme gene (cDNA)

JM109 derived fromE. coli K12 strain

- 5 -

Level B1
Cloning