Please read the following instructions carefully:

Please fill out the form completely and type ' NA' if not applicable
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.
 

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

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

TRAINING REQUIRED:

Hazardous Material Transportation (HAZMAT) training can be arranged through Environmental Health & Safety by calling 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
Proper Shipping Name:
Form of Material:
Type of Material:
Quantity of Material:
UN Number:
Manufacturer: (if any)
Shipping Destination:
Special Shipping Requirements:
i.e., cold packs, dry ice
Preferred Shipping Method:  
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)







 
b. Diagnostic Specimens:(check the appropriate one)




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