Dangerous Goods Shipment Request Form

Old Dominion University
Environmental Health & Safety

1. Shipper Information
Name Name * First Last
Requested Ship Date: Requested Ship Date: * / MM / DD YYYY
Department: *
Phone Phone * - ### - ### ####
Address: Address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email *
FedEx/ODURF Acct#:
(All DG Shipments are shipped by FedEx only).
* If your department doesn't have FedEx/ODURF Acct#, contact EH&S to arrange payment using IDT *
2. Destination Information
Name Name * First Last
Company: *
Department: *
Phone Phone * - ### - ### ####
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
3. Description of items being shipped:
Material to be shipped: *
Technical name: *
Manufacturer: *
Product Number: *
Physical State: *

Physical State: Liquid Solid Multi-phase (describe) Gas Other (describe)
Describe Multi-phase / Other:
Radioactive? *

Radioactive? Yes No
If Yes, provide Isotope and Activity: *
Biological? *

Biological? Yes No
If yes, does it contain a Risk Group 2, 3, or 4 pathogen? *

If yes, does it contain a Risk Group 2, 3, or 4 pathogen? Yes No
Pathogen name: *
Amount of material per container (mg, kg, mL, L): *
Container size: *
Number of containers: *
Container type: *

Container type: Glass Plastic Bag Plastic Metal can Ampule
4. Special Shipping Requirements:
Cold Packs: *

Cold Packs: Yes No
Dry Ice Required? *

Dry Ice Required? Yes No
Amount of Dry Ice required (in Kg): *
5. Certification

I certify that all the information provided on this form is true and accurate.
Signature: *
Date Date * / MM / DD YYYY

Dangerous Goods Shipment Request Form

Dangerous Goods Shipment Request Form

1. Shipper Information

2. Destination Information

3. Description of items being shipped:

4. Special Shipping Requirements:

5. Certification