Form 0920-0199 Permit to Import Human Remains

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

APPLICATION FOR PERMIT TO IMPORT INFECTIOUS HUMAN REMAINS INTO THE UNITED STATES

FORM APPROVED OMB NO. XXXXXXX EXP DATE MM/DD/YYYY

Guidance for completing this form is available at http://www.cdc.gov/od/eaipp/importApplication/. This form must be submitted at https://eipp.cdc.gov/. E-mail: [email protected]. Telephone: 404-718-2077. Please submit completed form only once. Permits are single use only.

SECTION A - Person Requesting Permit in U.S. (Permittee)

1. Permittee's Last Name

2. Permittee’s First Name

3. Permittee’s Organization

4. Physical Address (NOT a post office box)

5. City

6. State

7. Zip Code

8. Permittee’s Telephone Number

9. Permittee’s Email

10. Secondary Contact’s Name

11. Secondary Contact’s Telephone Number

12. Secondary Contact’s Email Name

CLICK HERE TO ADD ADDITIONAL ROWS (AUTHORIZED USERS OF THE PERMIT)

SECTION B - Sender of Imported Infectious Human Remains

1. Sender’s Last Name

2. Sender’s First Name

3. Sender’s Organization

4. Physical Address Outside of the U.S. (NOT a post office box)

5. City

6. State/Providence

7. Country

8. Postal Code

9. Telephone Number

10 Email

CLICK HERE TO ADD ADDITIONAL ROWS (ADDITIONAL SENDERS)

SECTION C - Shipment Information

1. Method(s) of Shipment a Commercial Carrier (e.g., FedEx) b Hand-carried by individuals listed in Section A

2. Expected date of import MM/DD/YYYY

3. Shipping container a Hermetically sealed casket b Leakproof container c Other (please describe):

SECTION D – Facility Processing Human Remains

1. Intended use(s) of imported agent(s) a Interment b Cremation c Other (please describe):

2. Provide a detailed description of the handling or manipulation of human remains (Describe any work with unenabled human remains outside of sealed transport container. e.g. cremation, embalming, identity verification.)

3. Building Location

4. Suite/Room Location

5. Laboratory

6. Safety Level X BSL-1 X BSL-2 X BSL-3 X Other please describe _____

7. Storage Only (Will not open human remains that have not been embalmed)

CLICK HERE TO ADD ADDITIONAL ROWS (Facility Processing Human Remains)

SECTION E – Cause of Death

1. Cause of death _________________ - Infectious biological agent(s) known or suspected _____________________________________

2. Date of death (MM/DD/YYYY):

SECTION F- Biosafety Measures

1. Primary Containment to be used (Check all that apply) a None (open bench) b Downdraft table c Fume Hood d Other (please describe):

2. Personal Protective Measures to be used (Check all that apply) a Gloves b Protective Gown/Clothing c Goggles d Face Shield e Facemask f Respirator: N95, N100, or Powered Air Purifying Respirator (PAPR) f Immunizations h Other (please describe):____________

3. Personnel Training provided (Check all that apply) a Risk(s) associated with the imported biological agent(s) b Hazardous Material Packing/Shipping c Other (please describe): ________________________

4. Has the permittee implemented biosafety measures commensurate with the hazard posed by the infectious biological agent, infectious substance, and/or vector to be imported, and the level of risk given its intended use? a Yes b No (Plan may be required to be submitted)

5. Anticipated disposition of Infectious Human Remains when work is completed a Will be interred b Will be transferred to location listed in SECTION G c Will be cremated (please complete Block 6)

6. If Agent(s) will be destroyed, list expected method(s) of destruction a Thermal: b Chemical (describe chemical):_____________________________________ c Other (please describe): _________________________________________

SECTION G – Final Destination(s) of Imported Infectious Human Remains

1. Will the permittee transfer the imported materials to locations not listed in Section D above. X Yes (complete items 2-21) X No

2. Last Name of Recipient at Destination

3. First Name

4. Destination Organization

5. Final Destination Address (NOT a post office box)

6. City

7. State

8. Zip Code

9. Telephone Number

10. Email:

11. Intended use(s) of imported agent(s) a Interment b Cremation c Other (please describe):

12. Provide a detailed description of the handling or manipulation of human remains (Describe any work with unenabled human remains outside of sealed transport container. e.g. cremation, embalming, identity verification.)

13. Building Location

14. Suite/Room Location

15. Laboratory

16. Safety Level X BSL-1 X BSL-2 X BSL-3 X Other please describe _____

17. Storage Only (Will not open human remains that have not been embalmed)

18. Primary Containment to be used (Check all that apply) a None (open bench) b Downdraft table c Fume Hood d Other (please describe):

19. Personal Protective Measures to be used (Check all that apply) a Gloves b Protective Gown/Clothing c Goggles d Face Shield e Facemask f Respirator: N95, N100, or Powered Air Purifying Respirator (PAPR) f Immunizations h Other (please describe):____________

20. Personnel Training provided (Check all that apply) a Risk(s) associated with the imported biological agent(s) b Hazardous Material Packing/Shipping c Other (please describe): ________________________

21. Has the permittee implemented biosafety measures commensurate with the hazard posed by the infectious biological agent, infectious substance, and/or vector to be imported, and the level of risk given its intended use? a Yes b No (Plan may be required to be submitted)

+ CLICK HERE TO ADD ADDITIONAL ROWS (Final Destinations of Imported Biological Agent(s) or Vector(s))

I hereby certify that all individuals listed in this application have the appropriate qualifications, experience and training to safely handle the agents being imported and that the information submitted in this application is complete and accurate to the best of my knowledge and belief. I agree to comply with all conditions, restrictions and precautions that may be specified in any permit that may be issued. Additionally, I agree to comply with all applicable regulations and guidelines that govern this transfer. I understand that failure to comply with the importation requirements may subject me to criminal penalties pursuant to 42 U.S.C. 271. I understand that any false statement made in this application may subject me to criminal penalties pursuant to 18 U.S.C. 1001.

SECTION H - Signature of Permittee

1. Permittee’s Signature (REQUIRED)

2. Permittee’s Printed Name (Print name)

3. Date Signed (mm/dd/yyyy)

Public recording burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0199)