University of Connecticut Research Sample Transportation

Date of transport Vehicle type used for transport Personal University Other State Agency Site provided

Person transporting the sample(s)

Name:

Department:

E-mail address:

Alternate Contact at the University (Name/Phone number)

Collection/pick up site

Site Name:

Site Location:

Alternate Contact at the Site (Name/Phone number)

Description of the sample(s)

	Human	Animal				List Microorganisms
Blood				Microorganisms
Other Body Fluids
Tissues/organs
Anatomical Specimens

Other:

Final destination of sample(s) (University building/room number)

Please print this screen to keep with the sample(s) during transport and click here to
Sample Material is for Diagnostic, Investigational or Teaching purposes only. It is for the exclusive use of the person and/or University department named above.