Hazardous Material Shipment Request
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Hazardous Material Shipment Request
Purdue University Account #:
FROM
TO
Name:
Name:
Building:
Company:
Room:
Telephone #:
Address 1:
Email Address:
Address 2:
Faculty Contact:
City:
State:
Ship Authorization:
Zip/Postal Code:
Telephone #:
PI Signature
United States of America
Insurance:
Monetary Value:
Country:
(if blank then $0.00 will be assumed)
Delivery Preference:
Preparation Instructions:
If cooling is required please provide the appropriate amount of dry ice
Priority Overnight
Standard Overnight
or ice packs, a cooler, and a box
nd
Improper or missing paperwork and/or packaging may result in delays
2
Business Day
rd
Please provide an SDS and original packaging whenever possible
3
Business Day
For shipping related questions please call REM at (765) 494-0121
OR
For radioactive shipments call REM at (765) 494-6113
Date Needed at Destination:
Transfer Agreement Information:
Does the PI have a material transfer agreement to send this to the recipient?
Yes
No
(see )
Was the material obtained through a material transfer agreement?
Yes
No
If you answered “Yes” to the above, does it allow transfer to another party?
Yes
No
Description of Material:
(No abbreviations or chemical formulas; include CAS numbers for characterized chemicals; gene or translated protein, bacterial strains etc.)
Number of containers and amount of material (e.g. 1 x 50 ml):
Flammable
Toxic
Corrosive
Reactive
Organic Peroxide
Infectious
Gas
Dry Ice:
kg
Nucleic Acid:
Is the nucleic acid sequence in itself or through its transcribed or translated products able to represent a significant
Yes
No
hazard to human, animal or plant health?
Can the nucleic acid sequence in itself or through its transcribed or translated products enhance another organism
Yes
No
into which it may be inserted or otherwise integrated, to cause serious harm to human, animal or plant health?
Recombinant DNA/Protein:
Does the material originate from an infectious source?
Yes
No
Are there any stability or degradation concerns about the material?
Yes
No (
if Yes, state reasons for concern below)
International shipments may be delayed by export control reviews.
Revised: March 5, 2014
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