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New York University
Hazardous Material Shipping Declaration
(Please Print)
Your name:
Date (MM/DD/YYYY):
HAZARDOUS MATERIAL GENERAL INFORMATION
Material Name:
Form of Material: □ solid □ liquid □ gas
Type of Material? □ chemical □ radiological
□ biological
Quantity of Material:
CAS Number: (if any)
Manufacturer: (if any)
Shipping Destination:
Special Shipping Requirements: (i.e., cold
packs, dry ice)
Preferred Shipping Method: (i.e. US Mail,
Fed Ex, UPS)
CHEMICAL INFORMATION
Percent concentration:
Other information:
RADIOLOGICAL INFORMATION
Radionuclide:
Activity:
Other information:
BIOLOGICAL INFORMATION
GENETICALLY MODIFIED ORGANISMS
□ Genetically modified microorganisms and organisms that are not infectious to humans or animals (i.e., are WHO Risk Group 1) and do not interact
in a way that could alter animals, plants, or microbiological substances in a way which is not normally the result of natural reproduction.
□ Genetically modified microorganisms and organisms that are not infectious (i.e., are Risk Group 1) but which are capable of altering animals,
plants or microbiological substances in a way which is not normally the result of natural reproduction.
□ Genetically modified microorganisms and organisms that meet the definition of infectious substances for humans (i.e., WHO Risk Groups 2-4)
□ Genetically modified microorganisms and organisms that meet the definition of infectious substances for animals only (i.e., WHO Risk Groups 2-4)
Microorganisms (bacteria, mycoplasms, viruses, fungi, etc.)
□ Microorganisms that are not infectious to humans or animals (i.e., are WHO Risk Group 1)
□ Microorganisms that meet the definition of infectious substances for humans (i.e., who Risk Groups 2-4)
□ Microorganisms that meet the definition of infectious substances for animals only (i.e., who Risk Groups 2-4)
□ Biological products containing pathogens in Risk Group 1; and those known NOT to contain pathogens in Risk Groups 2-4.
□ Biological products, including an experimental product or component of a product, subject to Federal (e.g., the FDA, or USDA) approval, permit,
or licensing requirements.
□ Biological products reasonably expected to contain pathogens in Risk Groups 2-4 that do not meet the requirements of the trade exemption above
AND meet the definition of infectious substances for humans.
□ Biological products reasonably expected to contain pathogens in Risk Groups 2-4 that do not meet the requirements of the trade exemption above
AND meet the definition of infectious substances for animals only.
□ Patient specimens are those collected directly from humans or animals for purposes such as research, diagnosis, investigational activities,
disease treatment and prevention:
□ specimen known to contain or suspected to contain a microorganism in Risk Group 1, or that does not contain a pathogen, or one in which the
pathogen has been neutralized or inactivated.
□ specimen with no known serious human or animal disease. [E.g. Tumors & clinical samples received by Cell Genesys]
□ Blood, blood products, and organs for donation.
□ specimen with known serious human or animal disease (Risk Group 4).
WARNING: Failure to comply in all respects with the applicable Dangerous Goods Regulations may be in breach of the applicable law, subject to
legal penalties. * This Declaration must be signed by the principal investigator or it will not be processed.
CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above.
Print name and title of signatory:
Campus address and phone:
P.I. Signature: *
Date: