Export Review Form

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Please complete the survey below.

This form is intended to be used to request an Export Review for any of the following
potentially export-controlled activities:

Shipping physical items (testing kits, chemicals, radioactive material, research equipment, hardware, biologicals, etc.) to a recipient outside of the United States; or
Sharing or transmitting (including by email) technical information, data, or software to a foreign national who is in the United States or to any recipient outside of the United States.

First and last name of individual filling out this form

* must provide value

Email address of individual filling out this form

* must provide value

Destination country or country of primary recipient:

* must provide value

First and last name of shipper

* must provide value

First and last name of PI / individual responsible for materials to be shipped

* must provide value

Institution

* must provide value

UNMC

UNO

Nebraska Medicine

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Primary College/Institute of the PI

* must provide value

Which Department in ______?

Which Department in College of Medicine?

* must provide value

Which Division of ______?

* must provide value

Other College/Institute - Please Describe:

* must provide value

Other CoM Department - Please Describe:

* must provide value

Preferred / requested date of shipment

M-D-Y

What kind(s) of item(s) will be exported?

* must provide value

Biological Material

Good(s)

Technology / Software

Chemical

How will the items be exported?

Commercial airline (hand carried / checked baggage)

Courier service (UPS, FedEx, DHL)

Freight forwarder

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Please upload the flight itinerary for this export.

Upload file

How many different items are you shipping?

* must provide value

Item 1: Name & Description:

* must provide value

Item 1: Make & Model:

* must provide value

Item 1: Quantities/Volumes:

Item 1: Company/Source Name:

* must provide value

Item 1: Total value (dollars):

* must provide value

Item 2: Name & Description:

* must provide value

Item 2: Make & Model:

* must provide value

Item 2: Quantities/Volumes:

Item 2: Company/Source Name:

* must provide value

Item 2: Total value (dollars):

* must provide value

Item 3: Name & Description:

* must provide value

Item 3: Make & Model:

* must provide value

Item 3: Quantities/Volumes:

Item 3: Company/Source Name:

* must provide value

Item 3: Total value (dollars):

* must provide value

Item 4: Name & Description:

* must provide value

Item 4: Make & Model:

* must provide value

Item 4: Quantities/Volumes:

Item 4: Company/Source Name:

* must provide value

Item 4: Total value (dollars):

* must provide value

Item 5: Name & Description:

* must provide value

Item 5: Make & Model:

* must provide value

Item 5: Quantities/Volumes:

Item 5: Company/Source Name:

* must provide value

Item 5: Total value (dollars):

* must provide value

If you are exporting six or more items, please upload the information as a spreadsheet using the template here. Please include all available information.

Upload file

Is there any additional technical information that would be helpful for the reviewers to know?

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Upload any additional relevant documents (e.g., technical specifications or flight itinerary)

Upload file

Are any items chemicals or contain chemical components?

* must provide value

Yes

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Please upload Safety Data Sheets (SDS) for all chemicals.

If SDS is not available - Complete and upload
Dangerous Goods Determination Form

Upload file

Is this a new compound synthesized at UNMC or not otherwise commercially available?

* must provide value

Yes

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If yes, please complete and upload a Dangerous Goods Determination Form

Upload file

Is the item a biological substance?

* must provide value

Yes

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Will any items be shipped on dry ice?

* must provide value

Yes

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Is the shipper of record, ______, certified by UNMC Environmental Health and Safety to ship biological substances and dry ice?

* must provide value

Yes

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Is the source of any material human or animal?

* must provide value

Human

Animal

Other

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Other - please describe

Where was the material acquired from?

* must provide value

Is the biological to be shipped classified as a select agent?

* must provide value

Yes

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Is the biological a pathogen, toxin, or a genetic element of a pathogen or toxin, even in attenuated form?

* must provide value

Yes

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If shipping a pathogen, toxin, or a genetic element of a pathogen or toxin, please describe.

* must provide value

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Are all micro-organisms present non-pathogenic for humans and animals?

* must provide value

Yes

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By professional opinion, is there only a minimal likelihood that pathogens are present in the specimens?

* must provide value

Yes

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If the specimens are shipped in media, please describe.

Are there batteries being shipped?

* must provide value

Yes

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Please provide the battery type and quantity to be shipped.

Please see the UNMC Battery Guide for reference

Is there magnetic material being shipped?

Yes

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Name of primary recipient (must be an individual):

* must provide value

Primary recipients institution or company:

* must provide value

Primary recipient's address:

* must provide value

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Primary recipient's phone:

Will the item be used by or subsequently shipped to someone other than the primary recipient?

Yes

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Secondary recipient's name:

Secondary recipient's company/institutional affiliation:

Secondary recipient's address:

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Secondary recipient's phone:

Will the item be exported through a third party, like a freight forwarder?

Yes

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Third party name:

Third party address:

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Third party phone:

What is the intended use of the item?
Please provide as much detail as possible.

* must provide value

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Will the export support the design, development, production, stockpiling, or use of nuclear explosive devices, chemical or biological weapons, or missiles?

* must provide value

Yes

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Are there any restrictions on the public release of the exported item?

* must provide value

Yes

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Please explain the restrictions.

Did UNMC originally receive the materials from someone else?

* must provide value

Yes

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If yes, from what entity were they received?

* must provide value

Were the items received under a written agreement (e.g., a material transfer agreement) and/or under any restrictions which would put conditions on the ability to transfer the materials to a third party?

* must provide value

Yes

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Please upload the agreement here.

Upload file

Is there any intellectual property that needs to be protected?

* must provide value

Yes

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Please identify and describe any intellectual property that needs to be protected.

Is there a need to place restrictions on what the recipient can do with the materials, or restrict their ability to transfer to third parties?

* must provide value

Yes

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Date

M-D-Y

Reviewed by export control office?

Yes

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Total number of items reviewed:

Determination:

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Export control approval:

Yes

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Restricted party screening or other documentation:

Upload file

Restricted party screening or other documentation:

Upload file

Restricted party screening or other documentation:

Upload file

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