Shipping Request Form - Environment, Health and Safety

Shipper:(Required)

First Last

Shipper Email:(Required)

Enter Email Confirm Email

Shipper Phone:(Required)

Principal Investigator:(Required)

First Last

Principal Investigator Email:(Required)

Enter Email Confirm Email

Principal Investigator Phone:(Required)

Shipping Address:(Required)

Street Address Address Line 2 City State ZIP Code

Recipient:(Required)

First Last

Recipient's Institution:(Required)

Receiving Address:(Required)

Street Address Address Line 2 City State ZIP Code

Shipping Details

Describe the source of the material, where it came from, what do we know or suspect about the source, medical history, likelihood of the presence of a pathogen, etc. (Do not include any patient-identifying information or other HIPAA-covered information, if applicable):

Material Name/Strain:(Required)

Material Type:(Required)

Please provide more information about this material type:(Required)

Is it possible that samples contain a human or animal pathogen?(Required)

What pathogen(s)? Include the name or strain:(Required)

Have materials been neutralized or preserved in any way?(Required)

Please provide more information as to how the materials have been neutralized or preserved:(Required)

Parafin embedded

Chemical inactivation (formalin, ethanol, trizol, methanol, etc.)

Other:

Please provide more "other" information as to how the materials have been neutralized or preserved:(Required)

Have materials been genetically modified?(Required)

What are the modifications?(Required)

Material Form:(Required)

Please provide more information about this material form:(Required)

Packaging total volume/amount:(Required)

Packaging Container Type:(Required)

Please provide more information about this packaging container type:(Required)

Packaging Temperature Requirements:(Required)

Please provide more information about the temperature requirements with this packaging:(Required)

Purpose:(Required)

Please provide more information about the purpose of this shipment:(Required)

Which of the following applies to the acquisition of this material?(Required)

Please provide more information about the acquisition of this material:(Required)

Do you have a material agreement in place?(Required)

If shipping internationally, have you completed the Export Control Form?(Required)

View the Export Control Form.

Have you applied for any permits (CDC, USDA, etc.)?(Required)

Additional Information:

Please provide any additional, relevant shipping information not already listed above.