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WEBSITE OF THE STATE OF SOUTH DAKOTA DEPARTMENT OF HEALTH
Kim Malsam-Rysdon, Secretary of Health

Specimen Collection Card Instructions

The newborn screening specimen collection card is a legal record; the submitter is legally responsible for the accuracy and completion of all information.

Inaccurate or missing information may affect the accuracy of the screening results and/or the ability to quickly notify the infant's care provider in event of abnormal screening results. ANY DELAY PUTS THE INFANT'S HEALTH AT RISK.

It is extremely important that every data field on the specimen collection card is filled out completely, accurately and LEGIBLY before collecting the specimen. All requested information is vital to ensuring proper testing, and timely follow-up of repeat or confirmatory testing. Collection card information is essential to the infant match between the contract newborn screening laboratory report, the State Hygienic Laboratory at the University of Iowa (SHL) and the South Dakota Department of Health Electronic Vital Records and Screening System (EVRSS).

  • Complete all data fields to avoid having specimen rejected or test results withheld;
  • Use a ballpoint pen, as soft-tip pens will not copy through to the carbon copies;
  • Use blue or black ink and stay within the limits of the designated boxes;
  • Avoid touching the filter paper before, during and after collection. Oils and other substances on hands can contaminate the card or the specimen itself;
  • Water, infant formulas, antiseptic solutions, glove powder, hand lotion, and other materials should not come in contact with the newborn screening card at any time through the screening process;
  • Do not apply stickers/labels or write in the lower right-side of the card in the area that says "For SHL Use Only", as it makes logging and tracking specimens in the lab very difficult;
  • Remove the 2nd ply for your facilities records; this copy is for the submitter;
  • Do not use adhesive tape;
  • Pre-printed labels supplied by SHL – verify information is correct for your facility;
  • Do not share collection card supplies with other facilities. This will cause a disruption/delay with the appropriate notification of the newborn screening laboratory results.
  • Discard any expired or damaged collection cards. Specimen will be deemed "poor quality" if collection card has expired.

Section - Infant: Information

Initial Screen vs. Repeat Screen

  • Check the appropriate box: "Initial" or "Repeat."
  • Initial screen is the first submission
  • Repeat screen is used for any subsequent specimen regardless of the reason (poor quality, early collection).

Collection Date

  • Use an eight-digit format (yyyy/mm/dd) for the newborn's date of collection. For example, a sample is collected on March 9, 2018, would be recorded as 2018 03 09.

Collection Time (24 hour clock)

  • Always use 24-hour clock (HH:MM) when entering the time of collection.
  • Validity of test results are specific to the exact age (in hours) of the infant, so an accurate time of collection is crucial.

Collector

Use unique identifier (initilas, last name, employee ID number, et.) for the person collecting the sample. Each submitting facility can determine its own unique identifier for internal use.

Infant's Medical Record #

  • The Infant's Medical Record # is for submitting facility's use only. Typically, the assigned Medical Record # is to track patient information within a facility.

Infant's Last Name, Infant's First Name

  • Record infant's last name.
  • It is important to list the infant's last name regardless of whether the guardian(s) has chosen a first name. Record first name if known.
  • Providing an incorrect name could potentially cause a delay in reporting abnormal results and impact the health of the infant.

Infant's Birth Date

  • Use an eight-digit format (yyyy/mm/dd) for the infant's date of birth. For example, an infant born on March 9, 2018 would be recorded 2018 03 09.

Infant's Birth Time (24 hour clock)

  • Always use 24-hour clock (HH:MM) when entering the time of collection.
  • Validity of test results is specific to the exact age (in hours) of the infant, so an accurate birth time is crucial.

Infant's gender check box

Document "M" for male or "F" for female. If unknown or ambiguous genitalia, indicate "Unknown."

Infant's Street Address, City, State, Zip Code

  • Infant's residence, providing complete address, city, state and zip code.
  • In the event of an adoption or other guardianship, record the address where the infant will reside. Accurate contact information is crucial for contacting the guardian in the event of an abnormal result or a need for retesting.

If multiple, A, B...etc

  • Very important to indicate multiple birth order. Use A = first born of the set, B = second born of the set, etc.
  • If collection is for a single birth, leave blank or put a line through the field or cross out.
  • This field is not in reference to the birth order of all pregnancies but the birth order of this pregnancy.

Gestation age at birth

  • Record in completed weeks only, no rounding up.
  • Accurate gestational age is critical for analyzing the results of newborn screening tests.

Feeding Method (Check all that apply) Check boxes = Breast Milk, Formula, TPN, None of the above

  • Check all types of feeding that apply within the last 24 hours. For example, if the infant has received both Total Parental Nutrition (TPN) and breast milk in the last 24 hours, check both boxes.
  • Breast milk: includes milk sourced from biological mother or donor milk
  • Formula: includes all special formulas and additives (e.g. Human Milk Fortifier, Beneprotein, etc.)
  • TPN: includes but not limited to Neonatal Venous Nutrition (NVN), Peripheral Parenteral Nutrition (PVN), Hyperalimentation (Hyperal), Starter TPN, any supplementation that includes amino acids, and/or any additional TPN products not mentioned.
  • None of the above: if infant is receiving fluids only and/or no other feeding method listed.

Current Weight

  • Record the infant's weight in grams at time of specimen collection.
  • DO NOT LEAVE BLANK – it is important to correctly record the infant's weight for accurate test results.

Transfusion (Any Blood Products):

  • This field MUST be marked "Yes" or "No" because transfusion status affects results. Missing information could lead to delays. If the infant was given any blood products BEFORE newborn screen collection, check "Yes." If the infant was NOT transfused or transfused after collection check "No."
  • Record the date of the most recent transfusion. If infant has received multiple transfusions, you only need to record the most recent date of transfusion.
  • Use an eight-digit format (YYYY/MM/DD) for the most recent transfusion date. For example, infant was last transfused on March 9, 2018, record as 2018 03 09.
  • Transfusion includes ALL blood products including, but not limited to, red blood cells, plasma, immunoglobulins and platelets.
  • If baby received a transfusion before delivery (intrauterine), mark "Yes" and record the date of the most recent transfusion.

Check if Infant is in NICU

  • Mark as appropriate (NICU/PICU)
  • Leave box blank if not in the NICU/PICU

Check if Infant has Meconium Ileus

  • Meconium ileus is known to interfere with the screening for cystic fibrosis. If meconium ileus is suspected, the screening algorithm for cystic fibrosis will change.
  • Check the box ONLY IF the infant has or is suspected of having meconium ieleus.
  • If not meconium ileus suspected, leave blank.

Section - Guardian

Guardian is considered the person with the legal authority to care for the infant. In most cases, this is the birth mother but can include other legal guardian relationships if birth mother is not the legal guardian.

Guardian Check Box, Mother, Other, Please Specify____________

  • For the South Dakota Newborn Screening collection card, the birth mother information is vital for the match of the metabolic record to the correct birth certificate. Birth mother information should ALWAYS be entered within the Guardian Section on the collection card. Mother is in reference to the biologic mother. If biological mother is legal guardian, check "mother."
  • For the special circumstances of guardianship if other than the birth mother such as adoption, surrogacy, or protective services please indicate here Please Specify______________. Accurate identifying information is crucial for contacting the guardian in the event of time-critical newborn screening results to ensure timely follow-up testing and medical intervention.

Guardian's Last Name, Guardian's First Name

  • Birth mother's last name followed by the first name.

Guardian's Birth Date

  • Birth mother's date of birth using an eight-digit format (yyyy/mm/dd)

Guardian's Gender check box

  • Indicate sex by checking male or female.

Guardian's phone number

  • In the event of time-critical newborn screening results, accurate contact information is critical to ensure timely follow-up testing and medical intervention.

Birth Mother's Maiden Name

  • The mother's maiden name is a required data element to match newborn screening test results to the birth certificate.

Section - Health Care Providers

Ordering Healthcare Provider's Last Name, First Name, Ordering Health care Provider's phone number

  • Name of ordering healthcare provider with the last name followed by first name.
  • Phone number with area code.

Facility of Birth (Name, City, State)

  • The "Facility of Birth" is a required data element to match newborn screening test results to the birth certificate.
  • Accurate information is required and should not be assumed this is the same as the submitting facility.
  • If the infant was born outside of a South Dakota birth facility (i.e. homebirth,or an out-of-state birth), please enter HOMEBIRTH and/or the abbreviation of the state the infant was born in (i.e. MN, IA, ND, WY, etc.).

Primary Care Provider's Last Name, First Name checkbox Check if same as above, Primary Care Provider's Phone Number

  • In the event of time-critical newborn screening results, accurate contact information regarding the healthcare provider who will care for the infant post discharge is vital to ensure timely follow-up testing and medical intervention.
  • When the Primary Care Provider is the same as the "Ordering Healthcare Provider" use the checkbox to indicate "same as above."
  • Name of primary healthcare provider/clinic with the last name followed by first name.
  • Phone number with area code.

Section - Submitting Facility

Specimen Collection Card - Submitting Facility

Submitting Facility's Name, Submitting Facility's Street Address, City, State, Zip Code

  • Enter the name of the hospital, clinic, or certified nurse midwife submitting the specimen.
  • Accurate street address information is required – many facilities have the same name and/or part of a larger healthcare organization.
  • Submitter information is used for reporting newborn screening laboratory results and invoicing.

Section – BAR CODE (sticker label of the unique identification number)

  • Important that all birthing facilities utilize the sticker/label (barcode number) which is the unique identification number on the Certifier's Worksheet for Completing the Birth Certificate.
  • Each birthing facility should have a process to place the unique identifier number (sticker with the barcode number) from the collection card onto the Certifier's Worksheet for Completing the Birth Certificate.
  • The unique identification number allows the matching of the infant's initial newborn screening laboratory results to their birth record.

Contact the SD Newborn Screening Program at 605-773-3361 or the contract newborn screening laboratory, the State Hygienic Laboratory at the University of Iowa at 1-515-725-1630 for questions regarding unusual situations and the best way to complete information on the newborn screening collection card information.