DELAWARE HEALTH & SOCIAL SERVICES Division of Public Health Laboratory REQUEST FOR ENVIRONMENTAL PREPAREDNESS TESTING Date: _________ Collection Time:_______ Page ___of____ DIRECTIONS: Complete this form for each BATCH of samples. Complete DPHL “Chain of Custody Form for Environmental Preparedness Samples” for EACH sample container. For clinical samples, use clinical forms. SUBMITTED SAMPLE INFORMATION Sample Type Number Submitted Test(s)n Requested? Check type below Check below _____ Opened Envelope/Letter _________ ____ Cyanide ____ Pesticides _____ Unopened Envelope/Letter _________ ____ Trace Metals ____ Volatile Organic Compounds _____ Powder _________ ____ Nerve Agents ____ Lewisites _____ Environmental Swab _________ ____ Mustard/Blister ____ Riot/Choking Agents _____ Liquid _________ ____ Culture ____ Ricin _____ Drinking Water _________ ____ PCR ____ Anthrax _____ Food [specify] _________ ____ TRF _____ Unknown _________ ____ Unknown [specify] _____ Mixed Sample _________ _____ BDS cartridge _________ Potential identity(s) of agents(s)? _____ Other [specify] _________ ______________________________________ ______________________________________ Total Number of samples? _________ ______________________________________ Potential number of exposed persons? ________ Source of samples? ______________________________________ Symptoms of exposed people? ______________________________________ _______________________________________________ Detailed description of sample(s): ______________________________________ Onset of Symptoms? (immediate, minutes, hours, days, etc.) ______________________________________ ______________________________________ _________________________________________________________ ______________________________________ ______________________________________ Other Additional information? _________________________________________________________ _________________________________________________________ _________________________________________________________ Initial "yes" or "no" next to each criterial for the specimen(s) in this batch. Yes No DPHL staff only The sample(s) is ... Properly stored during transport (see specimen collection guidenace)? _____ _____ _____ Separated by sampe type? _____ _____ _____ Labeled with facility/group or specimen identifier? _____ _____ _____ Properly contained with sorbent (no leaks or cracks)? _____ _____ _____ triaged? (Complete Field Triage Form - next page) _____ _____ _____ Packaged in a minimum of double layer containment? _____ _____ _____ Contains a minimum of two field blanks for each specimen type? _____ _____ _____ Contains a minimum of two lot blanks for each specimen type? _____ _____ _____ Contains an intact custody seal (2 layers) and is initialed and dated by collector? _____ _____ _____ Includes a Chain of Custody Sheet for each sample type? _____ _____ _____ Shaded area to be completed by DPHL personnel ONLY Priority of Testing (Circle): CRITIAL (Stat) MODERATE (Routine) EXERCISE Delaware PUblic Health Laboratory***30 Sunnyside Road***Smyrna, DE 19977***302.223.1520 (p)***302.653.2877 (f) DPHL Request for Environmental Preparedness Testing Updated 0708 Page 1 ***************************************************************************************************************************************** DELAWARE HEALTH & SOCIAL SERVICES Division of Public Health Laboratory 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 Form for Environmental Preparedness Samples” for EACH batch. Complete DPHL "Chain of Custody Form for Multiple Environmental Preparedness Samples" for each sample. Check Box(es) below Result Triage Information for Test Performed (Check box below) Complete this section for each test listed below. Detail any Negative Positive additional testing performed under "Other". ________________________________________________________________________________________________________________________________________ | | | | 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 CLEARNED FOR PREPAREDNESS ANALYSIS? Submitter printed name/signature: ______________________________________________________ YES NO DPHL received printed name/signature: __________________________________________________ Yes No Delaware PUblic Health Laboratory***30 Sunnyside Road***Smyrna, DE 19977***302.223.1520 (p)***302.653.2877 (f) DPHL Request for Environmental Preparedness Testing Field Triage Updated 0708 Page 2 ************************************************************************************************************************************************ DELAWARE HEALTH & SOCIAL SERVICES Division of Public Health Laboratory REQUEST 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. Complete "DPHL Chain of Custody for Environmental Preparedness Samples" for each sample container. UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ ___________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ Delaware PUblic Health Laboratory***30 Sunnyside Road***Smyrna, DE 19977***302.223.1520 (p)***302.653.2877 (f) DPHL Request for Multiple Environmental Preparedness Samples Updated 0708 Page 3 ************************************************************************************************************************************************** DELAWARE HEALTH & SOCIAL SERVICES Division of Public Health Laboratory REQUEST 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. Complete "DPHL Chain of Custody for Environmental Preparedness Samples" for each sample container. UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ ___________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ __________________________________________________________________________________________________________________________________________________ UNIQUE SAMPLE ID OR Sample Description (submitter, type, quantity Testing Requested? Check boxes LIMS BARCODE location, sample source, any additional or note below information, triage results if positive) Cyanide ____ Nerve Agents ___ Trace Metals ___ Mustard or Blister ____ Choking ____ Culture ____ PCR ____ TRF ____ Other (specify) ____ Delaware PUblic Health Laboratory***30 Sunnyside Road***Smyrna, DE 19977***302.223.1520 (p)***302.653.2877 (f) DPHL Request for Multiple Environmental Preparedness Samples Updated 0708 Page 4 ********************************************************************************************************************************************* DELAWARE HEALTH & SOCIAL SERVICES Division of Public Health Laboratory REQUEST FOR MULTIPLE ENVIRONMENTAL PREPAREDNESS SAMPLES SKETCH/NOTES Delaware PUblic Health Laboratory***30 Sunnyside Road***Smyrna, DE 19977***302.223.1520 (p)***302.653.2877 (f) DPHL Request for Environmental Preparedness Testing Updated 0708 Page 5 *********************************************************************************************************************************************************** DELAWARE HEALTH & SOCIAL SERVICES Division of Public Health Laboratory REQUEST FOR MULTIPLE ENVIRONMENTAL PREPAREDNESS SAMPLES SKETCH/NOTES Delaware PUblic Health Laboratory***30 Sunnyside Road***Smyrna, DE 19977***302.223.1520 (p)***302.653.2877 (f) DPHL Request for Environmental Preparedness Testing Updated 0708 Page 6 **************************************************************************************************************** Delaware Public Health Laboratory 30 Sunnyside Road Smyrna, DE 19977 Phone: 302.223.1520 Fax: 302.653.2877 CHAIN OF CUSTODY FOR ENVIRONMENTAL PREPAREDNESS SAMPLES Date:________ Collection Time:_________ Page ___of____ DIRECTIONS: Complete this form for each sample container. For clinical samples use clinical forms. Complete the “DPHL Request For Preparedness Specimen Testing” Form for each sample batch. Note the storage location if specimens are stored. If specimens are stored other than under ambient conditions, note the conditions in the reason area. Original Specimen Collected by (Print and sign) ________________________________________________ Collection Date: ______________________________ Collection Time: _____________________________ Sample ID: ____________________________________ Storage Conditions & Location: _______________ Number of specimens: __________________________ Security Conditions & Location: ______________ Specimen type: ________________________________ Container type: ______________________________ Brief Description of Sample(s): Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Received by: (print/sign): _________________________________________ Date: ____________ Time: __________ Organization: __________________________________________________________________________________________________ Relinquished by: ________________________________________________________________________________________________ Reason: _________________________________________________________________________________________________________ Shaded area to be completed by DPHL Personnel ONLY Priority of Testing (CIRCLE): CRITICAL (STAT) MODERATE (ROUTINE) EXERCISE Page ___of____ Revised 0708 CHAIN OF CUSTODY FOR ENVIRONMENTAL PREPAREDNESS SAMPLES Delaware Public Health Laboratory . 30 Sunnyside Road . Smyrna, DE 19977 . (302) 223-1520 [p] · (302) 653-2877 [f] DPHL Chain of Custody for Environmental Preparedness Samples Updated 0708 Page 1