SHIPPER’S DECLARATION FOR DANGEROUS GOODS

Shipper

Consignee

Air Waybill No.

Page of Pages

Shipper’s Reference Number (optional)

 Four completed and signed copies of this Declaration must be handed to the operator.

TRANSPORT DETAILS

 This shipment is within the limitations   prescribed for:

  (delete non-applicable )

Airport of Departure:

PASSENGER AND CARGO AIRCRAFT

CARGOAIRCRAFT ONLY

Shipment type: (delete non-applicable)

NON-RADIOACTIVE RADIOACTIVE Airport of Destination:

NATURE AND QUANTITY OF DANGEROUS GOODS

Dangerous Goods Identification

UN or ID No.

Proper Shipping Name Class or Division(subsidiary risk)

Packing Packing

Group   Quantity and Type of Packing Inst. Authorization

 Additional Handling Information Shipment is made under the provisions of ICAO

 Emergency contact 24-hr number:  CHEMTREC (800)424­9300 (PAML Acct.)

 I hereby declare that the contents of this consignment are fully and accurately  described above by the proper shipping name, and are classified, packaged  marked and labelled/placarded, and are in all respects in proper condition for  transport according to applicable International and National Governmental  Regulations. I declare that all of the applicable air transport requirements have  been met.

Name/Title of Signatory

Place and Date

Signature (See warning above)

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Customer Instructions for Completing the

Shipper’s Declaration for Dangerous Goods Form

Before preparing the Shippers Declaration, you must determine which template should be used.

Template choices are as follows:

PAML1 – Unknown Category A, with Dry Ice

PAML2 – Known Category A, with Dry Ice

PAML3 – Unknown Category A, no Dry Ice

PAML4 – Known Category A, no Dry Ice.

The following information must be completed on the Shippers Declaration:

1. Shipper: Enter in the Name, Address, and Phone number of your facility along with the

name of the person responsible for the shipment. Names should not be abbreviated.

2. Consignee: Enter in the Name, Address of the facility to which you are shipping the

specimens as well as the person responsible at that facility.

3. Air Waybill Number and Page of Pages: Enter the waybill number Page of Pages where

indicated. If there are multiple pages of the form that are being prepared, as in cases

where a large number of samples are being shipped, enter the number of pages as

indicated at the top of the form. An example of the format used would be “Page 1 of 3

pages,” “Page 2 of 3 pages,” etc.

4. Transport Details: Delete the inappropriate information by using several X’s to cross out

the section. Under almost all circumstances, you will cross out the section “CARGO

AIRCRAFT ONLY.” (unless you exceed 50 ml in a shipment). This will allow either

passenger or cargo aircraft to ship your samples.

5. Airport of Departure: Enter in the name or site code for the airport from which the

shipment is leaving. For example, the code for Spokane, WA is GEG.

6. Airport of Destination: Enter in the name or site code for the airport for which the

shipment is intended.

7. Shipment Type: Delete the inappropriate information by using several X’s to cross out

the section. All Packing Instruction 620 shipments from PAML and its affiliates will be

non-radioactive, so the shipper must cross out the RADIOACTIVE box.

8. The “Nature and Quantity of Dangerous Goods” section of the Declaration of Dangerous

Goods has several components and is presented according to the type of shipment being

made (see specific Examples for PAML 1, PAML 2, PAML 3, and PAML 4 below).

9. Additional Handling Information: The following information must be on the form: 24-

hour phone number of person responsible: “CHEMTREC (800)424-9300 (PAML

Account)”.

10. Declaration Approvals/Authorizations: The individual preparing the Shippers

Declaration must enter their name and title, the place and date of preparation of the

shipment, and then sign the Shippers Declaration.

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When complete, retain one signed copy of the Form and submit three copies with the

completed shipment. Print all 4 copies on red bordered paper. In cases where non-standard

shipments are being prepared, call PAML Dangerous Goods team @ (509)755-8125 for

guidance.

The following examples relate to the “Nature and Quantity of Dangerous Goods” section of the

Shipper’s Declaration of Dangerous Goods

PAML1 – Unknown Category A, with Dry Ice

1. UN or ID Number: UN 2814 is always used to identify Infectious Substance affecting

humans, (liquid). UN 1845 is used only to identify shipments containing carbon dioxide,

solid (dry ice).

2. Proper Shipping Name:

a. “Infectious Substance, Affecting Humans (Suspected Category A)”. These words

must be used exactly. Note: You are not required to enter the exact name of the

suspected organism if it is unknown. IATA Special Provision A140 allows the

term “Suspected Category A” as an entry.

b. Dry Ice (Carbon Dioxide, Solid): When shipping with dry ice, it must be listed as a

dangerous good as “Dry Ice”

3. Class or Division: There are two classes that apply to the shipments you will be making:

Class 6.2 is always used when shipping Infectious Substances. Class 9 is used only when

shipping with dry ice.

4. Subsidiary Risk: Leave this section BLANK for all shipments.

5. Quantity and Type of Packing:

a. For the Infectious Substance enter “1 fibreboard box x number of milliliters” inside

the package (NOT TO EXCEED 50 ML).

b. For Dry Ice, enter in the number of kilograms (kg) of dry ice contained in the

shipment, not to exceed 2.2 kg. (5 lbs.).

c. Enter “All Packed in One Fibreboard Box” below the description.

6. Packing Instruction: Enter “620” for Infectious Substances. Enter “954” for dry ice.

7. When shipping Category A, enter “A140” in the Authorization column for the IATA

special provision that allows the “Suspected Category A” statement.

PAML2 – Known Category A, with Dry Ice

1. UN or ID Number: UN 2814 is always used to identify Infectious Substance affecting

humans, (liquid). UN 1845 is used only to identify shipments containing carbon dioxide,

solid (dry ice).

2. Proper Shipping Name:

a. “Infectious Substance, Affecting Humans (Enter Name of Infectious Substance)”.

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b. Dry Ice (Carbon Dioxide, Solid): When shipping with dry ice, it must be listed as a

dangerous good as “Dry Ice”

3. Class or Division: There are two classes that apply to the shipments you will be making:

Class 6.2 is always used when shipping Infectious Substances. Class 9 is used only when

shipping with dry ice.

4. Subsidiary Risk: Leave this section BLANK for all shipments.

5. Quantity and Type of Packing:

a. For the Infectious Substance enter “1 fibreboard box x number of milliliters” inside

the package (NOT TO EXCEED 50 ML).

b. For Dry Ice, enter in the number of kilograms (kg) of dry ice contained in the

shipment, not to exceed 2.2 kg. (5 lbs.).

c. Enter “All Packed in One Fibreboard Box” below the description.

6. Packing Instruction: Enter “620” for Infectious Substances. Enter “954” for dry ice.

7. Authorization: Leave blank when a known Category A is shipped.

PAML3 – Unknown Category A, no Dry Ice

1. UN or ID Number: UN 2814 is always used to identify Infectious Substance affecting

humans, (liquid).

2. Proper Shipping Name: “Infectious Substance, Affecting Humans (Suspected Category

A)”. These words must be used exactly. Note: You are not required to enter the exact

name of the suspected organism if it is unknown. IATA Special Provision A140 allows

the term “Suspected Category A” as an entry.

3. Class or Division: Class 6.2 is always used when shipping Infectious Substances.

4. Subsidiary Risk: Leave this section BLANK for all shipments.

5. Quantity and Type of Packing: Enter “1 fibreboard box x number of milliliters” inside

the package (NOT TO EXCEED 50 ML).

6. Packing Instruction: Enter “620” for Infectious Substances.

7. When shipping Category A, enter “A140” in the Authorization column for the IATA

special provision that allows the “Suspected Category A” statement.

PAML4 – Known Category A, no Dry Ice.

1. UN or ID Number: UN 2814 is always used to identify Infectious Substance affecting

humans, (liquid).

2. Proper Shipping Name: “Infectious Substance, Affecting Humans (Enter Name of

Infectious Substance)”.

3. Class or Division: Class 6.2 is always used when shipping Infectious Substances.

4. Subsidiary Risk: Leave this section BLANK for all shipments.

5. Quantity and Type of Packing: Enter “1 fibreboard box x number of milliliters” inside

the package (NOT TO EXCEED 50 ML).

6. Packing Instruction: Enter “620” for Infectious Substances.

7. Authorization: Leave blank when a known Category A is shipped.