Notification of Intent To Ship Hazardous Materials

Please complete this section with accurate details about your Department.

Principal Investigator

Corresponding IBC Protocol (If Applicable)

Dept./Division Name

Phone Number

P.I. Email Address

Region

Please complete this section with accurate information about the person responsible for preparing the shipment.

Full Name

Phone Number

Email Address

Please indicate the training you have taken within the past 24 months that qualifies you to be responsible for this shipment: (If you have not completed training, STOP and call your campus Safety Services office.)

I have completed:

Please complete this section with accurate information about the materials being shipped.

Shipment Date

Est. Date of Delivery

Recipient Phone Number

Date For Safety Services Inspection

Time For Safety Services Inspection

Recipient Address

Recipient Full Name(s)

Describe you shipment. Include volumes in metric units, DOT classifications, packing group, and other pertinent label information.
Example: "Clinical specimen on dry ice, UN1845, class 9, packing group III"

Describe Your Shipment in Detail

Describe the Contents. Give proper shipping names, quantity (volume), and type of packaging.
Example:
"Proper Shipping Name: Infectious substance, affecting humans"
"Quantity: 10mL"
"Type of Packaging: All packed in one fibreboard box"

Proper Shipping Name*

Quantity

Type of Packaging

*Could be more than one in a package. Click "more" to add another entry. Click "-" to delete an entry.

I acknowledge that the above information is accurate.

I acknowledge that the responsible person indicated above is liable for the above listed shipment, and that person has been notified and aware of their liability for the above listed shipment.

I acknowledge that the responsible person indicated above HAS BEEN FORMALLY TRAINED BY TTUHSC SAFETY SERVICES in Hazardous Material Shipping or, if not by Safety Services, an ACCREDITED HAZARDOUS SHIPPING TRAINING COURSE within the last 24 months prior to preparation of this shipment and date of this form.

I acknowledge that all information contained within this form and my shipment meets all guidelines specified in TTUHSC OP 75.13 - Shipment of Hazardous and Infectious Materials.

By checking this box, I hereby place my mark indicating that I have "digitally signed" and render true and correct the above stated acknowledgements.

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