DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Delaware Public Health Laboratory 30 Sunnyside Road Smyrna, DE 19977 Phone: 302.223.1520 Fax: 302.653.2877 REQUEST FOR CLINICAL PREPAREDNESS TESTING Date/Time:_________ Page ___of____ DIRECTIONS: Complete this form for each BATCH of samples. Complete DPHL “Chain of Custody Form for Clinical Preparedness Samples” for EACH patient. SUBMITTED SAMPLE INFORMATION Sample Type Number Shipped Test(s) Requested? Check box(es) below Check type below ___ Cyanide ___ Pesticides ___ Urine ________________ ___ Trace Metals ___ Volatile Organic ___ Blood ________________ ___ Nerve Agents Compounds ___ Tissue ________________ ___ Mustard/Blister ___ Lewisites ___ Other (specify):__________ ________________ ___ Culture ___ Riot/Choking Agents ______________________________ ___ PCR ___ Ricin Total number of samples? _______________________ ___ TRF ___ Anthrax Number of adult patients? ______________________ ___ Other (specify): __________________________ Number of pediatric patients? __________________ _______________________________________________ Potential number of exposed persons? ___________ _______________________________________________ Symptoms of exposed people? ____________________ Potential identity(s) of agent(s)?_____________ ________________________________________________ _______________________________________________ Onset of symptoms? (immediate, minutes, hours, _______________________________________________ days, etc.) ____________________________________ Detailed Description of Sample(s): ____________ Other additional information: __________________ _______________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ _______________________________________________ Place a check in the appropriate box for each question below. For more details, please refer to DPHL's "Instructions for Specimen Packaging, Transport and Complete of Chain of Custody Form". DPHL The Sample(s) is… YES NO Staff Only Properly separated by sample type? ____ ____ _______________ Labeled by unique identifier and draw order? ____ ____ _______________ Properly individually sealed with evidence tape? ____ ____ _______________ Properly initialed by collector? ____ ____ _______________ Labeled with facility/group identifier? ____ ____ _______________ Properly stored? (4 degrees C blood, -70 degrees C urine) ____ ____ _______________ Properly contained with sorbent and has no leaks or cracks? ____ ____ _______________ Double bagged? (Biological Preparedness samples only) ____ ____ _______________ Sealed with evidence tape & initialed on each layer? (Chemical ____ ____ _______________ Preparedness samples only) Packaged using Packing Instruction 650 (Chemical Preparedness samples only)? ____ ____ _______________ Has the outside of bag been decontaminated? ____ ____ _______________ List Decontaminant used:________________________________________ LIST _______________ Includes a Clinical Chain of Custody Sheet for each patient? ____ ____ _______________ Shaded area to be completed by DPHL Personnel ONLY Priority of Testing (CIRCLE) CRITICAL (STAT) MODERATE (ROUTINE) EXERCISE Updated 01/03/06 Doc #35-05-20/07/03/92 DPHL CHAIN OF CUSTODY FOR CLINICAL PREPAREDNESS SAMPLES DPHL Lab ID# ____________ Collection date/Time: ______________________________________________ Page ____ of ______ DIRECTIONS: This form must be completed for each patient. Attach and complete "DPHL Request for Clinical Preparedness Testing Form" for each BATCH of samples. Original Specimen Collected by (Print and Sign):______________________________________ Date/Time:_________________ Submitter Information: (Please Print) Name ______________________________________________________________________________________________________________ Organization ______________________________________________________________________________________________________ Street Address ____________________________________________________________________________________________________ City, State, Zip Code _____________________________________________________________________________________________ Phone/Cell # ______________________________________________________________________________________________________ Email Address _____________________________________________________________________________________________________ Collecting facility/area information: Name/Organization _________________________________________________________________________________________________ Street Address ____________________________________________________________________________________________________ City, State, Zip Code _____________________________________________________________________________________________ Phone _____________________________________________________________________________________________________________ Description of sample submitted: Patient's Name: ______________________________________________________ Date of Birth:_____________________________ Patient's ID number:__________________________________________________ Gender (circle): M F UNK Clinical Diagnosis: __________________________________________________ Health Status: ____________________________ Suspected Agent(s): __________________________________________________ Field Analysis? Y N Number of Specimens: _________________________________________________ Specimen Type: ____________________________ Any Additional Information: _______________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ Test(s) Requested: ________________________________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Shaded area to be completed by DPHL Personnel ONLY Priority of Testing (CIRCLE): CRITICAL (STAT) MODERATE (ROUTINE) EXERCISE Updated 01/03/06 Doc #35-05-20/07/03/92 DPHL CHAIN OF CUSTODY FOR CLINICAL PREPAREDNESS SAMPLES DPHL Lab ID# ____________ Collection date/Time: ______________________________________________ Page ____ of ______ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Received by: (print/sign)______________________________________________________ Date:__________________ Time:______ Organization:__________________________________________________________________ Reason:________________________________________________________________________ Shaded area to be completed by DPHL Personnel ONLY CLEARED FOR PREPAREDNESS ANALYSIS? DPHL receiver-printed name/signature: __________________________________________________________________ YES NO Updated 01/03/06 Doc #35-05-20/07/03/92