IEM-1 Blood Test Form Screening Form.pdf
PDF 416 KB Posted
- Solicitation number
- 20DPP00466
- Issued by
- New Jersey
About this file
This document describes the New Jersey Department of Health's IEM-1 Newborn Screening Request Blood Test Form. The form is used for the state's Newborn Screening Program and is required for jurisdictions within Mercer County and Trenton City. The form includes various parts with detailed specifications for paper type, ink colors, perforations, barcodes, and other design elements. The contract opportunity T2664 is for the printing and supply of these IEM-1 forms, with an expiration date of April 30, 2022.
The contract requires the successful vendor to provide the printed forms according to the detailed specifications outlined in the document. No specific quantities or pricing details are provided. The contract is open to all qualified vendors, with no incumbents or set-asides mentioned. Funding for the contract comes from the New Jersey Department of Health's Newborn Screening Program budget.
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| File | Type | Posted |
|---|---|---|
| T2664 Vendor Bidder Data Sheet.docx | DOCX document | |
| T2664 Disclosure of Investments in Iran.pdf | ||
| T2664 Bid Amendment 1.docx | DOCX document | |
| T2664 Revised Bid Solicitation 5.18.20.docx | DOCX document | |
| T2664 State-Supplied Price Sheet~1.xlsx | XLSX spreadsheet | |
| T2664 Bid Amendment 4~2.docx | DOCX document | |
| T2664 Offer and Acceptance Page~1.pdf | ||
| IEM-1A Blood Test Screening Form.pdf | ||
| T2664 Vendor Quote Overview Form.docx | DOCX document | |
| T2664 Bid Amendment 3~1.docx | DOCX document | |
| T2664 Bid Amendment 2~1.docx | DOCX document | |
| T2664 Ownership Disclosure.pdf | ||
| T2664 Bid Solicitation Checklist.docx | DOCX document | |
| T2664 Subcontractor Utilization Form.pdf |
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Text version
Phone
Toll Free Fax.
Approved Not Approved
Signature
Print Name Date
Changes from previous job
1.
2. )
3. Added 3/16th Black Consecutive Number to filter per customer request
4. Replaced ID333 with ID0606 ink on Part 5
5. Updated lineholes to represent actual size
6. Moved variable information from filter to the Face of Part 4
7. Removed Meconium ileus from all parts per customer request
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC
ID0214_Rev3 11-Aug-2011
Attachment One (1) - IEM-1 Blood Test Form
Front of Form (Flap Folded) All measurements can vary +/- 1/16” (1.6mm).
Manufacturing equivalent substitutions allowed for demographic papers
Glue lines are between the stubs of parts 1, 2, 3, 4, and 6 and in between parts 4 and 5.
Total Form Length (flap folded)
10” (254mm)
Total Form Height
(all parts)
4” (106mm)
Dotted Magenta lines signify perf lines.
DO NOT REMOVE
THIS COVER FLAP
It is for the protection of the specimen and the specimen handlers.
OPEN this flap to uncover the circles for blood collection AND leave open while drying.
BEFORE submitting the specimen:
Make sure the spots are completely dry and the protective flap is folded over the dried blood spots.
Folded Flap: 1 1/2”Perf: 3/4”
BIOHAZARD
BABY’S LAST NAME (PRINT)
PARENT COPY
SN 19100001
Parents, Your baby has had his/her Newborn Screening blood test.
This is an important public health service that can protect your baby. Infants may look healthy but have certain rare health problems which can be found by this test.
A small amount of blood was taken from your baby’s heel and sent to the New Jersey Newborn Screening Laboratory for testing. The hospital has given you the brochure “These Tests Could Save Your Baby’s Life.” This brochure has more information about Newborn Screening.
Please take this notice to your baby’s doctor, who can get a copy of the results by contacting the Newborn Screening Laboratory.
New Jersey
Department of Health http://www.newbornscreening.nj.gov
Instructions to
Submitter:
After entering the newborn’s name, remove this copy and give it to the parents of this newborn.
Por favor lleve esta carta al doctor de su bebé.
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC D
O N
O T
U S
E T
H
IS
F O
R M
A
F T
E R
/3
/2
Dotted Magenta lines signify perf lines.
Part 1: 20# Green Bond
Black and Red 185 ink face, Black ink only on back, 3/16” Red 185 consecutive number on face, Shaded Words & Lines = 20%, 8 1/2” (215.9mm)
Perf: 3/4”
Total Form Height
(all parts)
4” (106mm)
BABY’S LAST NAME (PRINT)
PARENT COPY
SN 19100001
Instructions to
Submitter:
After entering the newborn’s name, remove this copy and give it to the parents of this newborn.
Parents, Your baby has had his/her Newborn Screening blood test.
This is an important public health service that can protect your baby. Infants may look healthy but have certain rare health problems which can be found by this test.
A small amount of blood was taken from your baby’s heel and sent to the New Jersey Newborn Screening Laboratory for testing. The hospital has given you the brochure “These Tests Could Save Your Baby’s Life.” This brochure has more information about Newborn Screening.
Please take this notice to your baby’s doctor, who can get a copy of the results by contacting the Newborn Screening Laboratory.
New Jersey
Department of Health http://www.newbornscreening.nj.gov
D O
N O
T U
S E
T H
IS
F
O R
M
A
F T
E R
/3
/2
Por favor lleve esta carta al doctor de su bebé.
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC
Face of Part 1 (copy on back) All measurements can vary +/- 1/16” (1.6mm).
Manufacturing equivalent substitutions allowed for demographic papers
Glue lines are between the stubs of parts 1, 2, 3, 4, and 6 and in between parts 4 and 5.
Perf: 3/4”
Total Form Height
(all parts)
4” (106mm)
Part 1: 20# Green Bond
Black and Red 185 ink face, Black ink only on back, 3/16” Red 185 consecutive number on face, Shaded Words & Lines = 20%, 8 1/2” (215.9mm)
Your baby’s specimen will be securely stored according to Department of Health policy.
The current policy is available on the Newborn Screening Program’s website:
http://www.newbornscreening.nj.gov.
Newborn Screening Laboratory
New Jersey Department of Health
P.O. Box 371
Trenton, NJ 08625-0371
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC
Back of Part 1 (copy on face) All measurements can vary +/- 1/16” (1.6mm).
Manufacturing equivalent substitutions allowed for demographic papers
Part 2: 16# White CB
Black and Red 185 ink face only, 3/16” Red 185 consecutive number, Code 128 barcode with one human readable, Shaded Words & Lines = 20%, 8 1/2” (215.9mm)
Dotted Magenta lines signify perf lines.
SN 19100001
Perf: 3/4”
NJDOH/NBS LAB COPY
Total Form Height
(all parts)
4” (106mm)
1 White
2 Black or African American
SPECIMEN SUBMITTED BY: Hospital Baby’s Physician
BABY’S LAST NAME (PRINT)
Birth Date Date of Sample
RemarksBirth Time Sample Time am pm am pm
Gender
M F
Birthweight gms
Transfusion PRIOR to sample collection?
If Yes, give date and time:
No Yes-:
Gestational Age wks
MOTHER’S NAME (LAST, FIRST) (PRINT) Mother’s Age
IEM-1
City, State, Zip
HOSPITAL NAME AND ADDRESS BABY’S PHYSICIAN NAME AND ADDRESS
BABY’S MEDICAL RECORD NO.Antibiotic?
No
Collector’s Initials / Date:
Breast
Formula
HAL/TPN
Other
Type of Feeding
No
Yes Multiple Birth?
If Yes, A, B, C, etc.:
Address Apt. #
New Jersey
Department of Health
INITIAL
NEWBORN
SCREENING
REQUEST
Mother’s Hispanic Origin
NoYes
Mother’s Race
3 Asian
4 American Indian/ Alaskan Native
5 Native Hawaiian or Other Pacific Islander
Telephone No.
8 Other
Yes
Telephone No.
H5782JAN 16
Mother’s Telephone No.
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC
Face of Part 2 (no copy on back) All measurements can vary +/- 1/16” (1.6mm).
Manufacturing equivalent substitutions allowed for demographic papers
2022-04-30
Part 3: 14.5# Canary CFB
Black and Red 185 ink face only, 3/16” Red 185 consecutive number, Code 128 barcode with one human readable, Shaded Words & Lines = 20%, 9 7/8” (250.8mm)
Total Form Height
(all parts)
4” (106mm)
Perf: 3/4”
SUBMITTER COPY
SUBMITTER COPY
KEEP THIS COPY FOR
YOUR RECORDS
STEP 1
FILL OUT
INFORMATION ON
FORM ACCURATELY
AND COMPLETELY
STEP 2
TEAR OUT AND KEEP
YELLOW COPY AS
PROOF OF SPECIMEN
COLLECTION
STEP 3
COLLECT BLOOD
SEE REVERSE OF FORM FOR
ADDITIONAL INSTRUCTIONS
SPECIMEN SUBMITTED BY: Hospital Baby’s PhysicianIEM-1
SN 19100001
New Jersey
Department of Health
INITIAL
NEWBORN
SCREENING
REQUEST
JAN 16 H5782
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC
Face of Part 3 (no copy on back) All measurements can vary +/- 1/16” (1.6mm).
Manufacturing equivalent substitutions allowed for demographic papers
Glue lines are between the stubs of parts 1, 2, 3, 4, and 6 and in between parts 4 and 5.
2022-04-30
1 White
2 Black or African American
BABY’S LAST NAME (PRINT)
Birth Date Date of Sample
RemarksBirth Time Sample Time am pm am pm
Gender
M F
Birthweight gms
Transfusion PRIOR to sample collection?
If Yes, give date and time:
No Yes-:
Gestational Age wks
MOTHER’S NAME (LAST, FIRST) (PRINT) Mother’s Age
City, State, Zip
HOSPITAL NAME AND ADDRESS BABY’S PHYSICIAN NAME AND ADDRESS
BABY’S MEDICAL RECORD NO.Antibiotic?
No
Collector’s Initials / Date:
Breast
Formula
HAL/TPN
Other
Type of Feeding
No
Yes Multiple Birth?
If Yes, A, B, C, etc.:
Address Apt. # Mother’s Hispanic Origin
NoYes
Mother’s Race
3 Asian
4 American Indian/ Alaskan Native
5 Native Hawaiian or Other Pacific Islander
Telephone No.
8 Other
Yes
Telephone No.
Mother’s Telephone No.
Part 5:
ID0606 ink face and back, 3/16” Black
Consecutive Numbers
Face only, Circles are
12.7mm ID, 2” (50.8mm)
Part 4: 33# White CF
Black and Red 185 ink face only, 3/16” Red 185 consecutive number, Code 128 barcode with one human readable, Shaded Words & Lines = 20%, 8 1/2” (215.9mm)
Perf: 3/4”
NJDOH/NBS LAB COPY
Total Form Height
(all parts)
4” (106mm)
SPECIMEN SUBMITTED BY: Hospital Baby’s PhysicianIEM-1
New Jersey
Department of Health
INITIAL
NEWBORN
SCREENING
REQUEST
JAN 16 H5782
SN 19100001
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC
Face of Parts 4 and 5 (copy on back) All measurements can vary +/- 1/16” (1.6mm).
Manufacturing equivalent substitutions allowed for demographic papers
Glue lines are between the stubs of parts 1, 2, 3, 4, and 6 and in between parts 4 and 5.
PerkinElmer 226 Ahlstrom
C o m p le te ly f il l c ir c le s w it h b lo o d
S N
2022-04-30LOT 112147 / 30310002
1 White
2 Black or African American
BABY’S LAST NAME (PRINT)
Birth Date Date of Sample
RemarksBirth Time Sample Time am pm am pm
Gender
M F
Birthweight gms
Transfusion PRIOR to sample collection?
If Yes, give date and time:
No Yes-:
Gestational Age wks
MOTHER’S NAME (LAST, FIRST) (PRINT) Mother’s Age
City, State, Zip
HOSPITAL NAME AND ADDRESS BABY’S PHYSICIAN NAME AND ADDRESS
BABY’S MEDICAL RECORD NO.Antibiotic?
No
Collector’s Initials / Date:
Breast
Formula
HAL/TPN
Other
Type of Feeding
No
Yes Multiple Birth?
If Yes, A, B, C, etc.:
Address Apt. # Mother’s Hispanic Origin
NoYes
Mother’s Race
3 Asian
4 American Indian/ Alaskan Native
5 Native Hawaiian or Other Pacific Islander
Telephone No.
8 Other
Yes
Telephone No.
Mother’s Telephone No.
Magenta circles signify line holes.
Perf: 3/4”
Total Form Height
(all parts)
4” (106mm)
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC
Back of Parts 4 and 5 (copy on face) All measurements can vary +/- 1/16” (1.6mm).
Manufacturing equivalent substitutions allowed for demographic papers
Glue lines are between the stubs of parts 1, 2, 3, 4, and 6 and in between parts 4 and 5.
Part 5:
ID0606 ink face and back, 3/16” Black
Consecutive Numbers
Face only, Circles are
12.7mm ID, 2” (50.8mm)
Part 4: 33# White CF
Black and Red 185 ink face only, 3/16” Red 185 consecutive number, Code 128 barcode with one human readable, Shaded Words & Lines = 20%, 8 1/2” (215.9mm)
N e w
J e rs e y D e p a rt m e n t o f H e a lt h
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IN
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S u b m it f ilt e r p a p e r c a rd s p ro m p tl y t o t h e a b o v e a d d re s s w it h in h o u rs
N O
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S p e c im e n s m a y b e u n s a ti s fa c to ry i f:
A ll c ir c le s n o t c o m p le te ly f ill e d
S a m p le s o v e rs a tu ra te d d u e t o l a y e ri n g o f b lo o d o r u s e o f c a p ill a ry t u b e s
S p e c im e n n o t a llo w e d t o d ry t h o ro u g h ly
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W A
R N
IN
G
S
.D o n o t to u c h s a m p le a re a
D o n o t u s e i f d a m a g e d
Dotted Magenta lines signify perf lines.
Magenta circles signify line holes.
Part 6: 32# Buff Ledger (Flap Open)
Black and Red 185 ink back only, 11 1/2” (292.1mm)
DO NOT REMOVE
THIS COVER FLAP
It is for the protection of the specimen and the specimen handlers.
OPENthis flap to uncover the circles for blood collection ANDleave open while drying.
BEFORE submitting the specimen:
Make sure the spots are completely dry and the protective flap is folded over the dried blood spots.
Folded Flap: 1 1/2”Perf: 3/4”
BIOHAZARD
Total Form Height
(all parts)
4” (106mm)
Form Name New Jersey IEM-1
Design ID
Version
Design Date 04/24/19 RC
Back of Part 6 (no copy on face) All measurements can vary +/- 1/16” (1.6mm).
Manufacturing equivalent substitutions allowed for demographic papers
Glue lines are between the stubs of parts 1, 2, 3, 4, and 6 and in between parts 4 and 5.
IV
D i
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