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    HEM-FO-01&02, Rev.02 - ID Forms

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    Hazelle karren Manabat
    This document contains forms for identifying whole blood samples submitted for hemoglobinopathy confirmatory testing. The forms collect information like the baby's name and date of birth, mother's name and ethnicity, date and location of sample collection, gender and physician details. The second page is a transmittal form that accompanies samples sent to the National Newborn Screening Confirmatory Center, listing the baby/mother names and NSC sample identification numbers. The forms are used to identify and track samples through the confirmatory testing process.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    HEM-FO-01&02, Rev.02 - ID Forms

    Uploaded by

    Hazelle karren Manabat
    95 views1 page
    This document contains forms for identifying whole blood samples submitted for hemoglobinopathy confirmatory testing. The forms collect information like the baby's name and date of birth, mother's name and ethnicity, date and location of sample collection, gender and physician details. The second page is a transmittal form that accompanies samples sent to the National Newborn Screening Confirmatory Center, listing the baby/mother names and NSC sample identification numbers. The forms are used to identify and track samples through the confirmatory testing process.

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    HEM-FO-01&02, Rev.02_ ID Forms

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    This document contains forms for identifying whole blood samples submitted for hemoglobinopathy confirmatory testing. The forms collect information like the baby's name and date of birth, mother's name and ethnicity, date and location of sample collection, gender and physician details. The second page is a transmittal form that accompanies samples sent to the National Newborn Screening Confirmatory Center, listing the baby/mother names and NSC sample identification numbers. The forms are used to identify and track samples through the confirmatory testing process.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    95 views1 page

    HEM-FO-01&02, Rev.02 - ID Forms

    Uploaded by

    Hazelle karren Manabat
    This document contains forms for identifying whole blood samples submitted for hemoglobinopathy confirmatory testing. The forms collect information like the baby's name and date of birth, mother's name and ethnicity, date and location of sample collection, gender and physician details. The second page is a transmittal form that accompanies samples sent to the National Newborn Screening Confirmatory Center, listing the baby/mother names and NSC sample identification numbers. The forms are used to identify and track samples through the confirmatory testing process.

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    © All Rights Reserved
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    HEM-FO-01, rev.

    02 WHOLE BLOOD SAMPLE IDENTIFICATION FORM


    Effectivity date: 04March2019
    For HEMOGLOBINOPATHY CONFIRMATORY TESTING NSC CODE

    CONFIRMATORY Lab Accession Number


    NSC Sample ID Number

    Baby’s Last Name Baby’s Name For Multiple Births

    Mother’s First Name Ethnicity


    M – Male Y – Yes / N - No 1 – Heel
    F - Female 2 - Venous
    Date of Birth (mmddyyyy) Date of Collection(mmddyyyy) Gender Transfused Specimen
    _
    Place of Collection/ Name of NSF Contact Number
    _
    Newborn’s Physician Contact Number
    ____To be filled up by confirmatory laboratory staff/analyst:_______________________________________________________________________
    HPLC Hemoglobin Pattern: ________________________ Date sample received/Courier: ___________________________
    Other clinic info: ________________________________ Age of baby at collection: _____________

    HEM-FO-02, rev.02 ADDRESS TO: Page ___of___


    Effectivity date: 04March2019 NATIONAL NEWBORN SCREENING CONFIRMATORY CENTER
    for HEMOGLOBINOPATHIES
    Rm. 106, Clinical Room, Institute of Human Genetics
    National Institutes of Health, University of the Philippines-Manila
    Pedro Gil St., Ermita, Manila
    Tel. No. (02) 526-1725

    BLOOD SAMPLE TRANSMITTAL FORM


    ___________________________________________________________
    (Name of Sending Newborn Screening Center/ Facility)

    With this package are the following blood samples for Hemoglobinopathy Confirmatory Testing:

    NSC Sample ID
    Name of Baby / Mother RECEIVED BY/DATE
    Number

    Prepared by: ______________________________________________ Date prepared: ____/_____/_____


    (Signature over printed name/Designation)
    Contact #: ______ _________________________________

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