Obtaining an Acceptable Specimen
Filling out the Newborn Screening Card (printable image):
- Legibly print ALL information in spaces provided using block capital letters.
- Hospitals are not encouraged to fill out second screen card, since much of the information changes.
- Doctor's offices should check any information filled out by the hospital to make sure it is correct.
- All information is required.
- Check specimen collection date for accuracy.
To view instructions, roll mouse over a part of the image.
If infant has been transfused, write date in space provided. Transfusions can affect results.
Retain this part for your records.
Used by UDOH lab to mark a specimen unacceptable.
Recall Screen Box: Mark only if instructed by program staff. This is used if another specimen is needed because of specimen being unacceptable or abnormal.
Birth Date: Results are based on baby's age and cannot be processed without birth date.
Birth Weight: Results are based on birth weight and cannot be processed without it.
Fill all seven circles with blood. The top two blood spots are sent off-site and MUST be filled in addition to the five below.
FOR UDOH LAB ONLY: Do not mark or place labels in these areas.
*If baby is adopted, write adoptive family information, or adoption agency and name of a contact person. We must be able to identify and connect the information from the second screen with the first screen. We must have an identifying name for the baby.
Medical Home information: Who is called in case of an abnormal screen and where to send results.
Infant's name and gender. Name may change from first to second screen. Please verify that it is accurate.
Sample Collection Date: Results are based on age of blood and cannot be processed without this date.
Mother's information*: This is used to identify the baby and mother, and to contact mother if there is a problem. ALL info is required.
Note expiration date: Form CANNOT be used after this date.
Special information used for interpretation of results: Mark all that apply.
Kit ID Number: Used to identify infant.