Massachusetts Department of Public Health

Massachusetts Department of Public Health

William A. Hinton State Laboratory Institute

Chemical Terrorism Response Laboratory

305 South Street, Jamaica Plain, MA 02130

Tel: 617-983-6650 Fax: 617-983-6662

Specimen Information:
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
Comments: ________________________________________________________________________________________________________

Ship To: 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.
  

General Information

• 
  The name and address of the agency shipping the specimens, including contact
  

Shipping Information

• 
  The time and date that the package was shipped
  

Contact Names

• 
  The name and title of the submitter and an alternate, if applicable
  

Contact Telephone Numbers

• 
  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.
  

Specimen Information

• 
  Indicate the total number and type of specimens (urine or blood) in the secondary container.
  

Shipping Address

• 
  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.
  

PS-CT-3-08 March 2009