Shipping Request Form : Environmental, Health, Safety, Risk and Emergency Management : Texas State University

Sender's Name *

Contact Number (Phone Must Be Answered After Hours) *

E-Mail Address *

What are you shipping? Be Specific. *

For instance, E. coli K-12, [not bacteria or E. coli] or sodium fluoride, solid.

If the material is a biological sample, is it a human, animal or plant pathogen, or infectious agent in a virulent or attenuated form (including pathogenic bacteria, viruses, viral vectors, parasites, fungi, algae, or prions)?

Is the material a genetically modified microorganism that does not meet the definition of an infectious substance or toxic material (e.g. recombinant E. coli K12 containing the GFP gene or Staphylococcus aureus with a gene deletion)? Genetically modified microorganisms are microorganisms in which genetic material has been purposely altered through genetic engineering in a way that does not normally occur naturally. Genetically modified microorganisms which do not meet the definition of toxic or infectious substances must be assigned to UN 3245 (GMMO).

What amount in mLs or gms are you shipping per inner container?

Example: 5 one mL plastic tubes or 125 grams in one glass container with plastic screwtop lid.

Total quantity in package in mLs or gms.

For biological specimens, are they in a preservative? If yes, list the preservative and in what volume in mLs.

Example: 30 mLs of ethanol per tube.

Is dry ice included? If yes, give weight of dry ice. Never ship “wet” ice. Use frozen gel packs if dry ice is not necessary.

Example: 5 lbs of dry ice

Are you providing packaging for the shipment? Yes/No (NOTE: Packaging must meet regulatory requirements for the material you are shipping. EHSREM keeps a limited supply of packaging materials on hand. If appropriate packaging materials are not available, there may be a delay while they are ordered. If EHSREM supplies packaging, sender is responsible for reimbursing the cost.)

Yes

No

If yes, describe packaging to include inner containers, absorbents, and UN specification markings (if applicable).

What type of outer container are you using?

(Example: cardboard box or Styrofoam box)

What are the dimensions of the outer container in inches?

(L X W X H)

What is the total weight of the package?

What is the Net Value of the material(s) in USD? (NOTE: Any value over $1 might be used to assess insurance and customs fees.)

What is the recipient's name (person and/or company or university), address, phone number and email address of the recipient?

For international shipments to the European Union (EU), what is the recipient’s Economic Operators Registration and Identification number (EORI #)?

When do you want to ship?

When do you want the shipment to arrive?

How do you want to ship?

Example: FedEx, UPS, Lone Star

If recipient is paying for shipping, provide FedEx, UPS account number and zip code

Is there a maximum shipping cost you do not want to exceed? (NOTE: All international shipments will be assessed an initial $300 customs fee which will be adjusted once shipment clears customs.)

Who is the assigned person in your department that will be processing the payment for the shipment?