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  • Hema Form

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    MMG-PATHOLOGY
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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, ethnicity, gender, date and location of sample collection, results of initial HPLC testing, and clinical information. The samples are sent to the National Newborn Screening Confirmatory Center for further analysis to confirm the presence of hemoglobinopathies like sickle cell anemia.

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    hema form

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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, ethnicity, gender, date and location of sample collection, results of initial HPLC testing, and clinical information. The samples are sent to the National Newborn Screening Confirmatory Center for further analysis to confirm the presence of hemoglobinopathies like sickle cell anemia.

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    © All Rights Reserved
    Скачайте в формате PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    62 просмотров1 страница

    Hema Form

    Загружено:

    MMG-PATHOLOGY
    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, ethnicity, gender, date and location of sample collection, results of initial HPLC testing, and clinical information. The samples are sent to the National Newborn Screening Confirmatory Center for further analysis to confirm the presence of hemoglobinopathies like sickle cell anemia.

    Авторское право:

    © All Rights Reserved
    Скачайте в формате PDF, TXT или читайте онлайн в Scribd
    Отметить как неприемлемый контент
    из 1

    HEM-FO-01, rev.

    00 WHOLE BLOOD SAMPLE IDENTIFICATION FORM


    Effectivity date: 03Jan2018
    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

    HPLC Hemoglobin Pattern: ____________________________ Other Clinical Info: _________________________


    REMARKS: ________________________________________________________________ UNCONTROLLED COPY

    HEM-FO-02, rev.00 ADDRESS TO: Page ___of___


    Effectivity date: 03Jan2018 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

    WHOLE BLOOD SAMPLE TRANSMITTAL FORM


    ___________________________________________________________
    (Name of Sending Newborn Screening Center/ Facility)

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

    Name of Baby / Mother NSC Sample ID Number

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


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

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