Exhibit_1_-_Collection_Kit_Example.pdf

MEDICAL/FEEDING HISTORY (Check all that apply)

PULSE OXIMETRY/CCHD SCREENPULSE OXIMETRY/CCHD SCREEN

HEARING SCREEN

SUBMITTER’S INFORMATION

BABY’S INFORMATION

MOTHER’S/GUARDIAN’S INFORMATION

PROVIDER’S INFORMATION

All TestsTests Requested

GALT

CFTR

NICU/SCN

Transfusion Date Time (24 Hr Clock)/ / :

TPN/SNAP

Lipids/Carnitine/MCT

Discharged

Delayed

No Supplies

Refused

Technical Problem

Submitting Facility’s/Provider’s ID #

Submitter’s Name/Address

In Utero Infection

Family History

Craniofacial Anomalies

ECMO

NICU

Both Hyperbilirubinemia AND Exchange Transfusion

Pass

Pass

ABR OAE

Right Ear:

Screen Method

If not screened, reason

Hearing Risk Status (Select all that apply)

Left Ear:Refer Pass Refer

Fail Not Performed Refused Echo

Lactose-Free Formula (Soy)

Meconium Ileus

Family History of CF

HGB Only

Male

Female

Unknown

DHS Custody

Adoption

Address

City State Zip

Apt. #

Telephone #

Mother’s Date of Birth

Physician Ordering NBS (Last, First)

Primary Care/Follow-up Physician (Last, First)

Provider ID#

Provider ID #

Mother’s Medicaid ID # Mother’s Last 4 of SSN

Alternate Telephone #

White

Black

Hispanic

Asian

American Indian

Pacific Islander

First Screen

Transferred to

Last Name First Name

Sex Race (Check all that apply)

Birth Date Time

Collection Date

Medical Record #

U s e b la c k o r b lu e i n k b a ll p o in t p e n o n ly

S e e f u ll i n s tr u c ti o n s f o r c o m p le ti o n o f fo rm o n b a c k p a g e

Gest. Age Birth Wt. (gm) Multiple

Birth Order A-H

First NameLast Name

Repeat Screen

Previous NBS Lab#

Phe Monitor

DO NOT WRITE HERE

ExpiredRefusedNot Screened Due To / /

Date of Final Screen

Do not write in this box

(24 Hr Clock):

Time (24 Hr Clock):

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-3

Oklahoma Newborn Screening (NBS) Form

To order forms, call the OSDH NBS Program (405) 444-6494

O D

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Part 1 - 21# White CB - 5 1/2” x 8 1/2” (±1/16”) - Prints Green 2418U Ink - Laser 3 of 9 Barcode MOD 43 with 2 Human Readables

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Exhibit 1: Collection Kit Draft Example

MEDICAL/FEEDING HISTORY (Check all that apply)

PULSE OXIMETRY/CCHD SCREENPULSE OXIMETRY/CCHD SCREEN

HEARING SCREEN

SUBMITTER’S INFORMATION

BABY’S INFORMATION

MOTHER’S/GUARDIAN’S INFORMATION

PROVIDER’S INFORMATION

All TestsTests Requested

GALT

CFTR

NICU/SCN

Transfusion Date Time (24 Hr Clock)/ / :

TPN/SNAP

Lipids/Carnitine/MCT

Discharged

Delayed

No Supplies

Refused

Technical Problem

Submitting Facility’s/Provider’s ID #

Submitter’s Name/Address

In Utero Infection

Family History

Craniofacial Anomalies

ECMO

NICU

Both Hyperbilirubinemia AND Exchange Transfusion

Pass

Pass

ABR OAE

Right Ear:

Screen Method

If not screened, reason

Hearing Risk Status (Select all that apply)

Left Ear:Refer Pass Refer

Fail Not Performed Refused Echo

Lactose-Free Formula (Soy)

Family History of CF

HGB Only

Male

Female

Unknown

DHS Custody

Adoption

Address

City State Zip

Apt. #

Telephone #

Mother’s Date of Birth

Physician Ordering NBS (Last, First)

Primary Care/Follow-up Physician (Last, First)

Provider ID#

Provider ID #

Mother’s Medicaid ID #

Alternate Telephone #

White

Black

Hispanic

Asian

American Indian

Pacific Islander

First Screen

Transferred

Last Name First Name

Sex Race (Check all that apply)

Birth Date Time

Collection Date

Medical Record # Gest. Age Birth Wt. (gm) Multiple

Birth Order A-H

First NameLast Name

Repeat Screen

Previous NBS Lab#

Phe Monitor

DO NOT WRITE HERE

ExpiredRefusedNot Screened Due To / /

Date of Final Screen

Do not write in this box

(24 Hr Clock):

Time (24 Hr Clock):

C H

A R

T C

O P

Y

D E

T A

C H

A N

D P

L A

C E

IN

M

E D

IC

A

L R

E C

O R

Part 2 - 14# Canary CFB - 5 1/2” x 9 1/4” (±1/16”) - Prints Green 2418U Ink - Laser 3 of 9 Barcode MOD 43 with 1 Human Readable

Oklahoma Newborn Screening (NBS) Form

To order forms, call the OSDH NBS Program (405) 444-6494 to

Mother’s Last 4 of SSN

Meconium Ileus

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C H

A N

D G

IV

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P A

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Baby’s Last Name Baby’s First Name

Newborn screening blood tests

Every baby born in Oklahoma is required to have blood tests performed during the first week of life in order to help in the early detection of a group of treatable medical conditions that can cause severe illness, developmental disability or death. These tests can all be performed using a small amount of blood usually collected when the baby is 24 to 48 hours old. The blood sample is sent to the

Oklahoma State Department of Health (OSDH) Public Health Laboratory for testing. Test results are usually available in 10-14 days. For a list of conditions that are screened for in Oklahoma, see the OSDH Newborn Screening Program website at http://nsp.health.ok.gov

Importance of newborn screening

A baby with one of the conditions in the newborn screening test panel may appear healthy at birth, which makes it difficult for healthcare providers to recognize clinically. Failure or delay in diagnosing and treating a baby with one of these conditions within weeks of life can lead to severe illness or death. Newborn screening blood tests help inform healthcare providers if your baby is at risk for one of these conditions. If your baby is found to have a disorder, immediate care by a medical specialist may be needed.

How will I get the test results for my baby?

Please, take this form with you to your baby’s first well child visit and ask for your baby’s newborn screening test results. If your baby’s healthcare provider does not have the test results and you have not been notified by mail, please call the OSDH Newborn Screening

Program at the number indicated on the reverse of this form when your baby is 3 weeks of age.

OKLAHOMA NEWBORN SCREENING PROGRAM

Oklahoma State Department of Health

Parent/Guardian Information Sheet

Part 3 - 16# White CB - 5 1/2” x 9 7/8” (±1/16”) - Prints Black and CF Ink (indicated in blue)

OKLAHOMA NEWBORN SCREENING PROGRAM

Oklahoma State Department of Health

Parent/Guardian Information Sheet

Will my baby need more testing?

Your baby’s healthcare provider or an OSDH Newborn Screening Program coordinator will contact you if your baby needs further testing. They will tell you why more tests are needed and what to do next. Retesting does not necessarily mean that your baby is sick, but rather is done to be sure there is not a problem.

Additional testing may be needed if:

• Test results were abnormal or unclear.

• Your baby was premature or sick at birth.

• The blood sample was collected before your baby was 24 hours of age.

• Your baby had a blood transfusion before the blood sample was collected.

• There was a problem with the blood sample.

• Your baby’s healthcare provider requests repeat testing.

What if I have questions?

If you have questions about your baby’s newborn screening tests or test results, contact your baby’s healthcare provider, visit the OSDH

Newborn Screening Program website at Oklahoma.gov/health/NBS, call the OSDH Newborn Screening Program at (405) 426-8220 or

1-800-766-2223.

Part 3 Backer - Prints Black Ink

T A

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Baby’s Last Name Baby’s First Name

Importance of newborn hearing screening Every baby born in an Oklahoma hospital is required to have their hearing checked before leaving the hospital. For infants born outside of a hospital, a screening should be completed no later than 1 month of life. Hearing screening is a quick, harmless and effective way to determine if an infant can hear sounds needed for proper development of speech and language.

Hearing problems need to be identified as early as possible. If an infant has a hearing loss, steps can be taken to help the infant learn to communicate.

Hearing loss can occur at any time after birth. If your baby has any box marked under Hearing Risk Status, it is recommended that your baby’s hearing be checked again by 6 months of age.

If for some reason your baby’s hearing was not screened, please call the Oklahoma State Department of Health Newborn Hearing Screening Program at the number indicated on the reverse of this form to ask about a location close to you where your baby’s hearing can be checked.

Will my baby need more testing?

The hearing screen results for your baby should be indicated in the box to the right.

• “Pass” for both ears = your infant’s hearing is sufficient for language development

• “Refer” for one or both ears = additional testing is needed. Your baby’s healthcare provider should refer you for additional hearing testing.

OKLAHOMA NEWBORN HEARING SCREENING PROGRAM

Oklahoma State Department of Health

Parent/Guardian Information Sheet

IMPORTANT

Please, take this form with you to your baby’s first well child visit to discuss the results with your baby’s healthcare provider.

HEARING SCREEN

Discharged

Delayed

No Supplies

Refused

Technical Problem

In Utero Infection

Family History

Craniofacial Anomalies

ECMO

NICU

Both Hyperbilirubinemia AND Exchange Transfusion

Pass

ABR OAE

Right Ear:

Screen Method

If not screened, reason

Hearing Risk Status (Select all that apply)

Left Ear:Refer Pass Refer

Date of Final Screen / /

Part 4 - 20# Pink Bond - 5 1/2” x 10 1/2” (±1/16”) - Prints Black and CF Ink (indicated in blue)

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OKLAHOMA NEWBORN HEARING SCREENING PROGRAM

Oklahoma State Department of Health

Parent/Guardian Information Sheet Your baby’s hearing

Hearing checklist

Your child’s most important learning and speech development will take place during the first few years of life. In these early years of development, your child learns how to communicate - first to understand what people say, and then to start talking. Any degree of undetected hearing loss can negatively impact a child’s speech, language, social and emotional development.

What if I have questions?

If you have questions about your baby’s newborn hearing test results, contact your baby’s healthcare provider, visit the OSDH Newborn Screening

Program website at https://nsp.health.ok.gov, call at (405) 426-8220 or 1-800-766-2223, or email the program at osdh.newbornhearing@health.ok.gov.

Your baby should be able to achieve the following milestones around the ages listed below. As the weeks and months go by, check to see if your baby can do most of the things listed. If your baby can’t, don’t wait - have your infant’s hearing tested. If you suspect a hearing loss or have a concern about your child’s hearing, contact your healthcare provider, an audiologist, or your county health department to find out about hearing testing.

- turns eyes toward sounds

- responds to mother’s voice

- enjoys rattles

- babbles “ba-ba” or ga-ga”

3 to 6 months

- startled by loud sounds

- quiets to your voice

- makes cooing sounds

Birth to 3 months

- responds to own name

- understands “no no” & “bye-bye”

- turns head toward soft sounds

9 to 12 months

- turns head towards sounds

- begins to imitate speech sounds

- babbles more frequently

6 to 10 months

- correctly uses “ma-ma” and “da-da”

- points to familiar objects when asked

- responds to singing/music

12 to 15 months

Part 4 Backer - Prints Black Ink

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K e e p p ro te c tiv e fla p o p e n d u rin g d ry in g

D o n o t le t b lo o d s p o ts to u c h a n y th in g

D o n o t a llo w w e t s p o ts to c o m e in c o n ta c t w ith e a c h o th e r.

W h e n c o m p le te ly d ry, fo ld p ro te c tiv e fla p o v e r b lo o d s p o ts

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S e ru m rin g s p re s e n t

In s tru c tio n s fo r C o lle c tin g B lo o d S p o t S p e c im e n s N o te

: D o not handle blood collection area of N ew born Screening Form before, during, or follow ing sam pling.

C o lle c t b lo o d s a m p le fro m o u te r o r in n e r b o rd e r o f h e e l

C o lle c tio n o f p o o r q u a lity s p e c im e n s w ill d e la y te s tin g

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Part 5 - 100# White Tag - 5 1/2” x 8 13/16” (±1/16”) - Prints Black, Green 2418U and Red 185 Inks Part 6 - 903 Lot W231

5 1/2” x 2 13/16” (±1/16”) - Prints Bio Black 586 Ink Tips to back of Part 5 with

EBF glue #1003 indicated in Green Circle size:11.8mm ID

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Part 8 Face - 100# White Tag - 5 1/2” x 12 11/16” (±1/16”) - Prints Black and Red 185 Inks Pt. 7 - One Strip of Laminating Film on Face indicated in Yellow 5 1/2” x 4 1/16” (±1/16”)

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E n te r h e a rin g s c re e n in fo rm a tio n o n th e rig h t s id e o f th e N

B S

F o rm u n d e r “H e a rin g S c re e n

P ro v id e D a te o f F in a l S c re e n

N o te : H ospitals should only provide the final hearing screening results. If a second screen is required, report O

N LY the second/final screen results.

In d ic a te

R ig h t E a r a n d L e ft E a r re s u lts u tiliz in g “x

N o te : Ensure only one result is selected per ear. To m ake corrections, use a single line through the incorrect result. Print the w ord “error” and initial the change. (e.g., x R efer Error AB)

In d ic a te

S c re e n M e th o d u s e d

R e a s o n N o t S c re e n d te : If infant is screened disregard this section.

If h e a rin g s c re e n c a n n o t b e p e rfo rm e d , in d ic a te th e re a s o n b y s e le c tin g th e a p p ro p ria te b o x in th e “If n o t s c re e n e d , re a s o n ” s e c tio n a D e la y e d

- if a h e a rin g s c re e n c a n n o t b e c o m p le te d b e fo re th e b lo o d s p e c im e n is s e n t a n d it is a n tic ip a te d th a t h e a rin g w ill b e s c re e n e d p rio r to d is c h a rg e (e

.g ., in fa n t in

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- if in fa n t d is c h a rg e d b e fo re a h e a rin g s c re e n c a n b e p e rfo rm e d c N o s u p p lie s

- if n o s u p p lie s a re a v a ila b le fo r th e h e a rin g s c re e n d R e fu s e d

- if th e p a re n ts

/g u a rd ia n re fu s e d a h e a rin g s c re e n e T e c h n ic a l P ro b le m

- if a te c h n ic a l is s u e p re v e n te d p e rfo rm a n c e o f a h e a rin g s c re e n

N o te : If a technical problem occurs, report issue to the N ew born H earing Screening Program

C o m p le te th e “H e a rin g R is k S ta tu s ” s e c tio n (s e e b e lo w

E n s u re th e re a re n o m a rk s in th e “S c re e n M e th o d ” b o x

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N o te : Be certain infant’s nam e and N BS Form

Serial N um ber are legible on the photocopy.

F a x a c o p y o f th e re s u lts to th e N e w b o rn

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C m p le te th e “H e a rin g R is k S ta tu s ” s e c tio n b y s e le c tin g a ll th a t a p p ly, if k n o w n

N o te : This m ay require review ing the patient’s chart or asking about fam ily history.

a F a m ily H is to ry

- if b lo o d re la tiv e s o f th e in fa n t h a v e a p e rm a n e n t h e a rin g lo s s th a t b e g a n in e a rly c h ild h o o d (e

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P a re n t E d u c a tio ta c h th e

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S h e e t (p in k s h e e

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Part 8 Backer - Prints Black and Red 185 Inks

SEND SPECIMENS

WITHIN 24 HOURS OF

COLLECTION

DO NOT REMOVE THIS

COVER FLAP

OPEN this flap to uncover the circles for blood collection. DO NOT touch circles.

Close this flap over blood spots when completely dry.

OPEN this flap while blood spots are drying.

• Air-dry blood spots at room temperature for

3-4 hours.

• Flap can be used to support filter paper horizontally while drying.

Use OSDH Courier Service or mail via USPS to:

Newborn Screening

Oklahoma State Dept. Health

Public Health Laboratory

4615 W. Lakeview Rd

Stillwater, OK 74075

INQUIRIES

NBS Public Health Lab:

(405) 564-7750

NBS Follow-up:

(405) 426-8220 or

(800) 766-2223

ORDERING NBS FORMS

Call (405) 444-6494 https://oklahoma.gov/health/ locations/public-health-laboratory/forms.html

STORAGE

Store NBS forms vertically in a clean, dry area, away from direct sunlight before and after sample collection.

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Il le g ib le w ri ti n g a n d i n c o m p le te i n fo rm a ti o n m a y d e la y t e s t re s u lt s

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