VT Biohazardous Materials Shipping Request Form

  • The Biosafety Office of Environmental Health & Safety must oversee the shipment of allbiohazardous materials.
  • Shipments are handled Monday-Wednesday.
  • EHS will provide secondary/outer packaging and labels
  • Sender/PI is responsible for FedEx account number and supplying dry ice, if required.

*Please emailthe completed form to:Biosafety group at EHS.

Date you would like to ship package:
Note: International shipments can take up to 2 weeks to coordinate. Domestic shipments require at least 3 business days notice.
Shipping From (Shipper)
Name of Principal Investigator:
Department:Bldg.and Room #:
Phone Number: E-mail:
Responsible Person: Responsible Person Phone:
Shipping To (Consignee)
Name: Phone #:
Institution/Business Name:
Address:
City: State: Zip Code:
Country:
Fed Ex account number for shipping charges:
You must contact the Office of Sponsored Programs, Cyndy Williams at or (231-3371) prior to shipping to determine if a Material Transfer Agreement (MTA) is necessary.
Material Transfer Agreement (MTA) in place? Yes No, not required per OSP
Will your shipment contain dry ice? Yes No We will let you know how much dry ice will be needed and you are responsible for having it on the shipment date.
What type of material are you shipping? Solid Liquid Both
  1. Please describe the material to be shipped.
  2. Does the material you are shipping contain anything that could be a pathogen (potentially infectious), e.g. bacteria, virus, parasite, fungus, rickettsiae, cell lines (either purposely administered or naturally occurring)? Yes No
  3. If yes, does it affect human, animal or plant? Check all that apply. HumanAnimal Plant
NOTE: If animal pathogen, a USDA permit might need to be obtained from the consignee (recipient).
  1. List the pathogens here, including the full name and strain:
  2. Is the material a specimen from a human or animal? Yes No
  3. If yes, based on the medical history, symptoms and local endemic conditions can you say “there is minimal likelihood that the specimen contains a pathogen”? Yes No

  1. What is the primary packaging, e.g. 50mL conical or 2mL screw-top microcentrifuge tubes?
  2. What is the volume of material in each primary?
  3. What is the quantity of primary containers?
All liquid primary receptacles must be individually secured with secondary or positive means, i.e. tape or paraffin.
Is this materialgenetically modified? Yes No
Will this shipment containchemicals, e.g. formalin, ethanol? Yes No
If yes, list all chemicals and quantities here. Use the full chemical name, including percentage:
Additional Comments:

EHS-Biological Safety Version 29/2015