Delaware Public Health Laboratory 30 Sunnyside Road Smyrna, DE 19977 Phone: 302.223.1520 Fax: 302.653.2877 REQUEST FOR ENVIRONMENTAL PREPAREDNESS TESTING Date:________ Collection Time:_________ Page ___of____ DIRECTIONS: Complete this form for each BATCH of samples. For clinical samples, use clinical forms. Complete DPHL “Chain of Custody Form for Environmental Preparedness Samples” for EACH sample batch. Complete DPHL “Chain of Custody Form for Multiple Environmental Preparedness Samples” for each sample. SUBMITTED SAMPLE INFORMATION Sample Type Number Submitted Test(s) Requested? Check box(es) below Check type below ___ Cyanide ___ Pesticides ___ Opened Envelope/Letter ________________ ___ Trace Metals ___ Volatile Organic ___ Unopened Envelope/Letter ________________ ___ Nerve Agents Compounds ___ Powder ________________ ___ Mustard/Blister ___ Lewisites ___ Environmental Swab ________________ ___ Culture ___ Riot/Choking Agents ___ Liquid ________________ ___ PCR ___ Ricin ___ Drinking Water ________________ ___ TRF ___ Anthrax ___ Food (specify):___________ ________________ ___ Other (specify): __________________________ ___ Unknown ________________ _______________________________________________ ___ Mixed Sample: ________________ _______________________________________________ ___ BDS cartridge ________________ Potential identity(s) of agent(s)?_____________ ___ Other (specify):__________ ________________ _______________________________________________ ________________________________________________ _______________________________________________ Total number of samples? _______________________ Source of samples?_____________________________ Potential number of exposed persons? ___________ _______________________________________________ Symptoms of exposed people? ____________________ _______________________________________________ ________________________________________________ Detailed Description of Sample(s): ____________ Onset of symptoms? (immediate, minutes, hours, _______________________________________________ days, etc.) ____________________________________ _______________________________________________ Other additional information ___________________ _______________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ _______________________________________________ DPHL The Sample(s) is… YES NO staff only Properly stored (See specimen collection guidance)? ____ ____ _______________ Separated by sample type? ____ ____ _______________ Labeled with facility/group identifier? ____ ____ _______________ Properly contained with sorbent (no leaks or cracks)? ____ ____ _______________ Triaged? (Complete Field Triage Form - next page) ____ ____ _______________ Double bagged? ____ ____ _______________ Outside of bag decontaminated? ____ ____ _______________ Decontaminant used:________________________________________ LIST _______________ Individually sealed with evidence tape and initialed by collector? ____ ____ _______________ Including Chain of Custody Sheet for each sample type? ____ ____ _______________ Shaded area to be completed by DPHL Personnel ONLY Priority of Testing (CIRCLE) CRITICAL (STAT) MODERATE (ROUTINE) EXERCISE Updated 01/03/06 REQUEST FOR ENVIRONMENTAL PREPAREDNESS TESTING FIELD TRIAGE FORM DIRECTIONS: Complete the table below for each sample batch.For clinical samples, use clinical forms. Complete and attach “DPHL Chain of Custody for Environmental Samples” for each batch. Complete DPHL “Chain of Custody Form for Multiple Environmental Preparedness Samples” for each sample. Check Box(es) below Result? (Check box below) Triage Information for Test Performed Negative Positive Complete this section for each positive test. ________ ________ Explosives: Name/Organization: Date/Time: Test/Instrument used: Identity of material(s): ________ ________ Radiation: Name/Organization: Date/Time: Test/Instrument used: Identity of material(s): ________ ________ Chemicals: Name/Organization: Date/Time: Test/Instrument used: Identity of material(s): ________ ________ Biologicals: Name/Organization: Date/Time: Test/Instrument used: Identity of material(s): ________ ________ Other (specify): Name/Organization: Date/Time: Test/Instrument used: Identity of material(s): ________ ________ Other (specify): Name/Organization: Date/Time: Test/Instrument used: Identity of material(s): Shaded area to be completed at DPHL ONLY CLEARED FOR PREPAREDNESS ANALYSIS? Submitter printed name/signature: _______________________________________________________________________ YES NO DPHL receiver printed name/signature: ___________________________________________________________________ YES NO Updated 01/03/06 CHAIN OF CUSTODY FOR ENVIRONMENTAL PREPAREDNESS SAMPLES DIRECTIONS: Complete this form for each sample batch. For clinical samples use clinical forms. Complete the “DPHL Request For Environmental Sample Testing” Form for each sample batch. Complete DPHL “Chain of Custody Form for Multiple Environmental Preparedness Samples” for each sample. 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 _____________________________________________________________________________________________________ Describe sample(s) collection area: Name/Organization __________________________________________________________________________________________________ Street Address (Intersection) ______________________________________________________________________________________ City, State, Zip Code ______________________________________________________________________________________________ Phone ______________________________________________________________________________________________________________ Location (floor, region, or area) __________________________________________________________________________________ Other descriptor: __________________________________________________________________________________________________ Description of sample submitted: Suspected agent(s):___________________________________________________ Collection Time:_____________________________ Number of specimens:__________________________________________________ Specimen type:_______________________________ Any additional Information __________________________________________________________________________________________ Description of Sample(s):____________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 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 CHAIN OF CUSTODY FOR ENVIRONMENTAL PREPAREDNESS SAMPLES 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:________________________________________________________________________ Updated 01/03/06 CHAIN OF CUSTODY FORM FOR MULTIPLE ENVIRONMENTAL PREPAREDNESS SAMPLES DIRECTIONS: Complete this form for each sample and specimen type with multiple preparedness samples. Complete “DPHL Request for Environmental Preparedness Testing” for each batch submission. Sample Sample Description: submitter, type, quantity, location, TESTING REQUESTED? Number sample source, any additional information, triage results Check boxes below if positive Cyanide, Nerve Agents,Trace Metals, Mustard or Blister, Choking, Culture, PCR, TRF, Other (Specify): CY NA TM M/B CHK CUL PCR TRF OTHER 1 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 2 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 3 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 4 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 5 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 6 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 7 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 8 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 9 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 10 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 11 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ 12 ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ Updated 01/03/06 CHAIN OF CUSTODY FORM FOR MULTIPLE ENVIRONMENTAL PREPAREDNESS SAMPLES DIRECTIONS: Complete this form for each sample and specimen type with multiple preparedness samples. Complete “DPHL Request for Environmental Preparedness Testing” for each batch submission. Sample Sample Description: submitter, type, quantity, location, TESTING REQUESTED? Number sample source, any additional information, triage results Check boxes below if positive Cyanide, Nerve Agents,Trace Metals, Mustard or Blister, Choking, Culture, PCR, TRF, Other (Specify): CY NA TM M/B CHK CUL PCR TRF OTHER ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___ ___ ___ ___ ___ ___ ___ ___ ______ ________________________________________________________ ________________________________________________________ Updated 01/03/06