Hazaradous Material Shipping Declaration Form

Texas Tech University

EHS Home

Asbestos Management

Environmental Protection

Institutional Biosafety Committee

Hazardous Material Shipping Declaration Form

DHS-Appendix A of the CFACTS

EHS Internal Only

Please read the following instructions carefully:

Please fill out the form completely and type ' NA' if not applicable
Also a copy of the submitted form will be sent to you and MailTech by email.
Once the form is submitted, it will be reviewed by EH&S and you will be contacted if necessary.
If you have any questions, please contact EH&S at 742-3876.
Click Here to Add this page to My Favorites.

The United States Department of Transportation (DOT) requires that all Hazardous materials be shipped according to Federal Regulations (49 CFR 100-185). These regulations require the shipper or person preparing the package for shipment to receive training and prepare the shipment with required packaging, marking, labeling, and shipping documents. These regulations affect all employees at Texas Tech preparing packages for shipment that meet the definition of a hazardous material (a material listed in 49 CFR 172.101).

Procedures

Any person preparing shipment must complete a Hazardous Material Transportation training course every two years.
Submit form 24 hrs. prior to shipping package. You will be contacted by an Environmental Health & Safety representative with further instructions.

Training

Hazardous Material Transportation (HAZMAT) training can be arranged through Quality Service and Professional Development online or by calling 742-0530.

For further information, contact Matt Roe at (742-3876).


`SENDER INFORMATION`
`Date`
`Name`
`Department`
`Department Phone No`	enter your phone number (xxx-xxx-xxxx)
`Home/Cell Phone Number`	enter your 24 hr contact no. (xxx-xxx-xxxx)
`Fax`
`Email`	enter your email (eg. Krish.Raya@TTU.EDU)
`HAZARDOUS MATERIAL GENERAL INFORMATION`
`Material Name`
`Form of Material`	SolidLiquidGas check the appropriate one
`Type of Material`	ChemicalRadiologicalBiological check the appropriate one
`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, FedEx, UPS
`Shipment #`	(to be filled in by TechMail only)
`CHEMICAL INFORMATION`
`Percent Concentration`
`Other Information`	type additional information
`RADIOLOGICAL INFORMATION`
`Radionuclide`
`Activity`
`Other Information`	type additional information
`BIOLOGICAL INFORMATION a. Microorganisms (bacteria, mycoplasms, viruses, fungi, etc.)(check the appropriate one)`
Microorganisms that are not infectious to humans or animals (i.e., are Risk Group 1) Microorganisms that meet the definition of infectious substances for humans (i.e., Risk Groups 2-4) Microorganisms that meet the definition of infectious substances for animals only (i.e., 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. Not Applicable
`b. Diagnostic Specimens(check the appropriate one)`
Diagnostic (clinical) 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. Diagnostic specimen with no known serious human or animal disease. Blood, blood products, and organs for donation. Diagnostic specimen with known serious human or animal disease (Risk Group 4). Not Applicable

`SPECIAL INSTRUCTIONS !!!!`
`If the package has been damaged or is leaking during shipping, refer to DOT emergency response book.`

`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.`
CERTIFICATION `: I hereby certify that the contents of this consignment are fully and accurately described above.`
`P.I. Signature: (Type your name in full)`
`A completed and signed copy of the declaration must be submitted to EH&S at least one week prior to your expected shipping date of any material that may be classified as a hazardous material. A Material Safety Data Sheet should be included with this Declaration whenever possible. EH&S will determine what regulations, if any, apply to your shipment. You will be responsible for providing all appropriate packaging materials required for your shipment.`

For additional Information contact EH&S at 742-3876. If you have any problems/comments with this form contact webmaster.

Label


	Environmental Health and Safety \| 2903 4TH Street Rm 122 \| Lubbock \| Texas 79409-1090 Phone: 806.742.3876 \| Fax: 806.742.3895 \| Maintain By: Abdullah Muqim Copyright 2009 Texas Tech University \| All Rights Reserved \| Last Updated 05.14.2009