DEHS Shipment Request Form for Biological Samples

Completion of this form will provide DEHS with the information needed to prepare a shipment of biological materials and/or dry ice. DEHS will review the information provided on this form to assist the shipper in ensuring that the shipment is packaged, marked, labeled, and documented in compliance with applicable domestic and international shipping regulations. Additional information may be needed to satisfy export compliance and technology transfer concerns. Please complete and submit this form at least 48 hours before planned shipping date.

 

NOTE: Do NOT complete this form for shipments of Hazardous Materials (chemicals) or Radioactive Materials.  For Hazardous Materials (chemicals), contact DEHS Hazardous Waste office at 852-2956.  For Radioactive Materials, contact the Radiation Safety Office at 852-5231.


Shipper is IATA/DOT Certified?  Certification date must be current (within 3 years).


NOTE: IATA/DOT training is required for any individual who: prepares the package; marks and/or labels the shipping paperwork; and receives (signs for) the package.
This is a preliminary request, I do not have a shipment date.  


This is an actual shipment request, I have a set ship date of:
//  
Is this an international shipment?  


This will be an air shipment  


This will be a Ground Shipment.  


Will this be a recurring shipment?  


If YES, until what date?
//  
NOTE: For recurring shipments, the classification of the material must remain the same. If the hazard category or hazard class changes, you must submit a new request.
NOTE: If more than one material is being shipped to the same recipient, enter each material name and type, number of containers and size in the comments section of this form (up to 4 additional).
Material is derived from University Research?  


If yes, are pathogens expected to be present?


Material is diagnostic specimen?  


If yes, are pathogens expected to be present?


Material is research specimen?  


Material is a select agent?  


Material is infectious to humans?  


Material is infectious to animals?  


Material is genetically modified?  


Material has other known biological or infectious hazards?  


Shipment will contain Dry Ice?  


Shipment will be shipped in a dry dewar (insulated flask in which refrigerated liquid nitrogen is the refrigerant)?  


 

Department of Environmental Health And Safety

Main Office

1800 Arthur Street

Louisville, Kentucky 40208

Phone

tel (502) 852-6670

fax (502) 852-0880

Department of Environmental Health And Safety

Radiation Safety Office

319 Abraham Flexner Way

Louisville, Kentucky 40202

Phone

tel (502) 852-5231

fax (502) 852-8911

Office Hours

M-F 8:00 am to 4:30 pm

No holiday hours

IH Service Account

dehsih@louisville.edu

IBC Service Account

biosafe@louisville.edu