Chemical Exposure Clinical Specimen Shipping Manifest
DIRECTIONS: Please fill out this form completely and put in a zip-loc plastic bag. Place the bag on top of the secondary container. Please use one form per shipping container.
Shipped By: ______________________________________
Time: __________AM / PM (circle one)
Contact Telephone Numbers:
1. Total number of specimens __________
2. Indicate which type of specimen is being shipped (only check one):
Blood (refrigerated) with refrigerator packs
Urine (frozen) with dry ice
Massachusetts Department of Public Health
William A. Hinton State Laboratory Institute
305 South Street
Jamaica Plain, MA 02130
Attn: Dr. Jennifer Jenner, CT Coordinator
617-983-6650 (lab) / 617-839-1283 (cell)
Filling out Chemical Exposure Clinical Specimen Shipping Manifest
One form should be used for each secondary container.
The form should be put in a ziplock plastic bag and placed on top of the secondary container located inside the Styrofoam container.
Contact Telephone Numbers
The time and date that the package was shipped
Provide telephone, fax, and/or emergency numbers that the submitter can be reached. If the package is breached during transit or the receivers have questions about the specimens, it is very important to be able to contact the submitter immediately.
Indicate the total number and type of specimens (urine or blood) in the secondary container.
Because it is very important to have the correct and complete address of the receiver; please use the complete SHIP TO address provided on the shipping manifest.
Please remember to call the receiver BEFORE sending specimens, so they can know 1) when to expect the package and 2) who is delivering the package.
If you have any questions, please call the telephone number provided above.