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DI-18-301 Declaration Form For Exempt Human Animal Specimens and UN3373

The document is a declaration form for shipping human/animal specimens and infectious substances. It asks a series of yes or no questions to determine if the specimen is properly packaged and labeled according to regulations for transporting infectious substances and whether it contains clinical waste. The bottom of the form is for listing contents, quantity, and weight being shipped and includes boxes to check off if the substance is classified as infectious or contains dry ice.

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Shashank Parate
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6 views2 pages

DI-18-301 Declaration Form For Exempt Human Animal Specimens and UN3373

The document is a declaration form for shipping human/animal specimens and infectious substances. It asks a series of yes or no questions to determine if the specimen is properly packaged and labeled according to regulations for transporting infectious substances and whether it contains clinical waste. The bottom of the form is for listing contents, quantity, and weight being shipped and includes boxes to check off if the substance is classified as infectious or contains dry ice.

Uploaded by

Shashank Parate
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Declaration form

Shipment of exempt human/animal specimens and

UN3373 DG: Infectious Substances not harmful to humans/animals

Please circle or strike off as required pertaining to the specimen to be shipped:

1. Does the specimen contain clinical waste? E.g. syringes, swabs not rendered safe
from hazards to any person coming into contact with it
Yes / No If yes, go to A
2. Is the specimen submitted for diagnostic purposes to an authorised lab? Yes / No
• If no, kindly state where it will be delivered to and for what purposes:
_______________________________________________________
3. Is the specimen infectious or reasonably known to be infectious? Yes / No
If yes, go to 4 and tick the UN 3373 box at the bottom of the page. If no, go to 5.
4. Is the specimen, if exposed, known or reasonably known to be or cause any of the
below to humans or animals?
• Life-threatening Yes / No
• Permanent disability Yes / No
• Death Yes / No
5. Proper packaging
• Is the specimen packed in a primary receptacle? Yes / No
• Are there separate specimens? If so, are they separately packed? Yes / No
• Is there a rigid secondary receptacle? Yes / No
• If solid, is it sift proof? Yes / No
• If liquid, is it leak proof? Yes / No
• If liquid, is there absorbent material around the primary receptacle to soak
up the liquids in the cause of leakage? Yes / No
6. Quantity
• Does each primary receptacle store no more than 1 litre or 1 kg of specimen?
Yes / No
• Does the entire package not exceed 4 litres or 4 kgs of specimen? Yes / No
7. Resilience of packaging
• Will it reasonably stay intact in the course of air transport? Yes / No
• Can it stay intact from a drop of 1.2 m? Yes / No
• Can it withstand a pressure of 95 Pa? Yes / No
8. Does the packaging contain ice? Yes / No
9. Does the packaging contain dry ice? Yes / No
If yes, declare this in the UN 1845 box below and go to 10. If no, go to 11
10. Can gases escape and is it rupture proof? Yes / No
11. Are there interior supports inside to secure secondary packaging once it is
melted/dissipated? Yes / No
12. Can the receptacles maintain their integrity at low temperatures? Yes / No

A) This item is not allowed to be shipped via Postal mail. Kindly seek another service
provider and we apologise for the inconvenience.

If you are unsure of how to answer any of the above questions, kindly speak to our friendly
Post Office Counter Staff.

Contents Quantity Weight

Dangerous Goods Declaration

☐ UN3373 (Infectious, not harmful to humans/animals)


☐ UN1845 (Dry Ice)

Signature: _______________

Contact number: _________________

Date: _______________

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