Declaration of Biological Products (Proof of Classification
Transcription
Declaration of Biological Products (Proof of Classification
Declaration of Biological Products (Proof of Classification) Document de classification des produits biologiques SHIPPER: Name: Address: City: Province: Country: Postal Code : Country of origin: RECEIVER: Name: Address: City: Province: Country: Postal Code : Country of origin: Emergency Contact name /Phone number: / CHECK ONE BOX/COCHER UNE SEULE CASE: *Exempt human specimen *Exempt animal specimen This biological product is: Non-Infectious/Not-Restricted Biological Substance, Category B, UN 3373 Matières biologiques, Catégorie B, UN 3373 Dry Ice, UN 1845 Neige carbonique, UN1845 * Exempt Human/Animal Specimen were collected from healthy individuals/animals Dry Ice as refrigerant / Neige carbonique comme réfrigérant: YES / NO Scientific name of the biological product / Nom scientifique du produit biologique: Description and quantity of the biological product / Description et quantité du produit biologique: Final use of the biological product / Usage final du produit biologique: For research purposes only In vivo In vitro Additional requirements: YES / NO If yes, please specify: _________________________________________________________________________________________________ Shipper’s Signature EHS reference # (BP) EHS-FORM-005 v.4 Print name/Nom en lettres moulées EHS Name Date Signature Date(YYYY-MM-DD) 1/1