How to Complete the Blood Collection Form

 

The following is provided to help you complete each field of the newborn screening blood collection card. It is hoped that this information will assist in improving the completeness and accuracy of the information provided on the card. All data field information is read and keyed by newborn screening data entry personnel so legibility is a must. Please print neatly.

Click HowToComplete-WebSave for a visual chart of this page’s instructions to print and use in your facility.

Click NBSWeightChart-WebSave for a handy conversion chart showing pounds/ounces to grams, and standard time to military time.

If you would like laminated copies of either or both of these charts, please contact us: NBSqualityreport@slh.wisc.edu

  • BABY’S NAME:  Record the newborn’s last name followed by first name.
    • No need to write boy, girl, infant, etc.
  • MULTIPLE BIRTHS: #1 of 2, #2 of 2, etc.
  • SEX: Circle either F for female or M for male.
  • BIRTHDATE AND TIME: Record birthdate as MM/DD/YY and the time in military time. (Example: 1 PM = 1300; 11:30 PM = 2330)
    • Completion of this field is critical as it is used for normal range determination.
  • BABY’S ID # (optional): Record the appropriate hospital or medical record number
    • This is not a required field. If provided, the baby’s ID number will appear on the report issued for that specimen. This may be helpful to you in matching an issued report to the appropriate baby.
  • BABY’S PCP: Enter the last AND first names of the baby’s primary care provider, the 10-digit NPI #,clinic name and city, and clinic phone #.
    • The newborn screening statute requires the laboratory to contact the PCP when test results are abnormal. Both normal and abnormal results are sent to the PCP and submitter.
  • ORDERING PHYSICIAN / NPI#
  • SPECIMEN COLLECTION DATE AND TIME: Record the specimen collection date as MM/DD/YY and the time in military time. (Example: 1 PM = 1300; 11:30 PM = 2330)
    • Completion of this field is critical as it is used for normal range determination.
  • BIRTHWEIGHT (grams): Record weight in grams.
    • Completion of this field is critical as it is used for normal range determination.
    • The gestational age should be rounded up if 4 or more days beyond full week (e.g., 38 weeks + 4 days = 39).
    • Do not add current age to gestational age.
  • MOTHER’S NAME: Record the mother’s last name followed by the first name.
    • The mother’s first and last name are essential when inquiring about a baby’s testing status or requesting an additional report.
  • GESTATIONAL AGE: Record the newborn’s week of gestation at time of birth.
  • BABY’S RACE / HISPANIC: Circle the appropriate race of the baby.
    • If the baby is of mixed race, circle all that apply.
    • For Hispanic babies, circle Hispanic and the appropriate race.
    • Race information is important for abnormal result reporting.
  • BABY IN NICU: Circle N for no or Y for yes.
  • REPEAT SPECIMEN: Circle N for no or Y for yes.
  • REASON FOR REPEAT: Circle the appropriate reason the baby is being retested.
  • TRANSFUSION(S): Circle N or Y. If Y is circled then record the date of the LAST transfusion.
    • For babies that have been transfused, the transfusion date is the important factor for determining whether the test results are valid.
    • If the infant was transfused in utero, circle Y and record “prior to birth” if exact date is unknown.
  • CHILD ON TPN NOW?: Circle N or Y. Circle Y if the baby is on Total Parenteral Nutrition at the time of the specimen collection.
  • BIRTH FACILITY: Record the name and city of the facility where the birth occurred.
    • If born at home, record Home Birth.
    • If born in another state or country, do not include the name of the hospital, just the state/country.
  • SEND REPORT TO: If the report is to be sent to a place different from the submitter and physician, record the agency name (if known) and complete address.

HEPATITIS SCREENING

          • MOTHER’S HEPATITIS B SURFACE ANTIGEN: Circle NEG if the mother’s test result is non-reactive or negative. Circle POS if the mother’s test is reactive or positive.
            • This information is very important to assure that infants of HBsAG positive mothers receive proper immunizations.
            • Do not confuse hepatitis antibody results for hepatitis surface antigen results.

HEARING SCREENING (PINK SECTION)

          • HEARING SCREEN DATE: Record the date screened if different from the blood specimen collection date.
          • RIGHT EAR: Check Pass if the hearing results are normal. Check Refer if hearing results are abnormal.
            • If the right ear is not screened, circle the appropriate reason in the NOT SCREENED section of the form.
          • LEFT EAR: Check Pass if the hearing results are normal. Check Refer if hearing results are abnormal.
            • If the left ear is not screened, circle the appropriate reason in the NOT SCREENED section of the form.
          • CIRCLE HEARING SCREEN METHOD: Circle ABR for the auditory brainstem response method (also abbreviated as AABRR). Circle OAE for the otoacoustic emissions method (also abbreviated as TEOAE or DPOAE).
            • Circle BOTH if each method is used.
          • HEARING NOT SCREENED REASON: If the hearing screening was not performed prior to blood screening, circle the appropriate reason. If Other is selected write in the reason why hearing screening was not performed.

PULSE OX SCREENING (YELLOW SECTION)

          • DATE AND TIME SCREENED: Record the date as MM/DD/YY and the time in military time. (Example: 1 PM = 1300; 11:30 PM = 2330)
            • Do not record the time below the yellow pulse ox box; this area (BLUE SECTION) is needed for laboratory use.
          • PULSE OX RESULT: Check only one box – Pass, Fail, or Not Screened.
            • NOT SCREENED: If Pulse Ox screening was not performed prior to blood screening, check the appropriate reason. If Other is selected, write in reason why Pulse Ox screening was not performed.

Reporting of CCHD results should NEVER delay the submission of the blood card. If CCHD pulse ox testing has not been done by the time the blood specimen is ready, photocopy the newborn screening blood card and ship the original blood card. The CCHD screening results can be recorded on the photocopy of blood card, and then sent to the Wisconsin State Laboratory of Hygiene.

BLOOD NOT SCREENED: This newborn screening form must be completed regardless of whether blood screening is performed. If the blood screening was not performed, check the appropriate reason. If Other is selected, write in the reason why blood screening was not performed. Forms without blood sample collection will be replaced without charge on a monthly basis.

 

QUESTIONS?

Please contact the Newborn Screening Laboratory at 608-262-6547.