Poliovirus Containment Data

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Personal Details:

Full Name*

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Designation*

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Affiliation / Organization:*

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Telephone no:

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E-mail *

Facility Details

A facility is defined as any site (e.g. laboratory, repository or vaccine production unit) owned or operated by any level of government, academic institution, corporation, company, partnership, society, association, firm, sole proprietorship or other legal entity.

Country:*

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State/Region/Province: *

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District: *

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Name of the facility: *

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Facility Address: *

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Facility E-mail:

Type of Organizations:*

District: Please enter the type of agencies/institutes.

Sector:*

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Specialty: *

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Facility Phone: *

Note: Please use international format. i.e. +962XXXXXXXXXX

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Facility Fax:

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Does your laboratory have a sample storage capacity? *

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Survey Form:

* All fields are compulsory

#	Indicator	Answer	#	Indicator	Answer
a	Number of Fridge with Freezer Compartments Standard home refrigerator		b	Number of Refrigerator (+2°C to +8°C)
c	Number of Freezer ( -10°C to -19°C)		d	Number of Freezer ( -20°C or -69°C)
e	Number of Freezer ( -70°C or below)		f	Number of Liquid Nitrogen Storage Tanks
2.	Does your laboratory test for any reason?
a	Any sample for poliovirus culture?	Yes No	b	Any genetic material for poliovirus culture?	Yes No
c	Any poliovirus vaccine?	Yes No
e	Date of last poliovirus sample tested?		f	Date of last poliovirus material stored?
3.	Does your laboratory test for any reason?
a	Fecal/stool specimen	Yes No	b	Respiratory specimen (throat swabs, nasal swabs etc.) - PIM	Yes No
c	Cerebrospinal Fluid	Yes No	d	Water sample	Yes No
e	Environmental sample	Yes No	f	Agricultural sample (Sludge water etc)	Yes No
g	Animal specimen for poliovirus	Yes No	h	Biological specimen for poliovirus	Yes No
4.	Does your laboratory "store" in the freezer?
a	Fecal/stool specimen	Yes No	b	Throat and nasal swabs (e.g., respiratory, COVID-19, influenza specimens	Yes No
c	Water sample	Yes No	d	Environmental sample	Yes No
e	Agricultural sample (Sludge water etc)	Yes No	f	Enterovirus or untyped enterovirus samples/isolates	Yes No
g	Animal specimen for poliovirus	Yes No	h	Biological specimen for poliovirus	Yes No
i	Any infected or potentially infected poliovirus material sample collected in foreign country Infected Material (IM) is biological material confirmed to contain pathogens that can cause disease. Potentially Infected Material (PIM) refers to substances that may contain infectious agents but are not confirmed to do so.	Yes No	j	Any sample material of poliovirus?	Yes No
k	Any poliovirus seed or vaccine bulk?	Yes No