Having accurate and legible information entered onto the newborn screening card is the important first step in the newborn screening process. Please print clearly using blue or black ink. An attempt should be made to complete all fields. Incomplete or inaccurate information may result in inconclusive or erroneous newborn screening (NBS) results. Do not use correction fluid on the card to cover errors. If an error is made in completing the form, cross through the error and print the correct information above.
1. Baby’s Name:
Last Name: Enter the baby’s last name as it will appear on the birth certificate. If the baby’s last name is unknown, then the mother’s last name should be entered as the baby’s last name. If the last name is a hyphenated name (i.e. Smith-Jones), include a hyphen in a separate box on the form.
First Name: Enter the baby’s first name as it will appear on the birth certificate. Do not enter “Baby Boy,” “Baby Girl,” “Infant” or a hospital ID in this field. If the baby’s first name is unknown, leave the field blank. Historically, this field has been completed on fewer than 50 percent of specimens. The first name is helpful in identifying a child for follow-up when the last name has changed. Please make an effort to routinely complete this field.
2. Baby AKA:
Complete this field only if the baby is known by more than one name (i.e. if the baby’s last name has changed). This field can also be used to indicate custody issues by entering “Adoption,” “Safe Haven,” or “Foster Care” or a baby’s death by entering “Expired” followed by the date of death.
3. Medical Record Number:
Enter the baby’s medical record or ID number at the facility submitting the specimen
4. Birth Order if Multiple: (for multiple births only)
Use alphabet designation (i.e. A, B, C etc) to indicate baby’s order of birth.
5. Gestation (in Weeks):
Enter the baby’s gestational age at birth in weeks based on physical exam (preferred) or last menstrual period.
6. Birth Date and Time:
Enter the date and time of birth (use military time: noon = 1200, midnight = 0000). This information is necessary for interpretation of results; if these fields are incomplete, the NBS results may be reported as inconclusive. When the specimen is being collected on an infant/child who is older than 7 days, the birth time is not essential for interpretation of results.
Indicate the baby’s sex by filling in the correct circle [M= male; F = female; A = ambiguous (sex is unassigned due to abnormal genitalia or other congenital anomalies) U = unknown (sex is assigned, but unknown to the person completing the form)]
8. Current weight:
Enter the weight of the baby at the time of specimen collection. The baby’s weight can be reported in either grams (preferred) or pounds and ounces. For specimens collected in the newborn period, the birth weight should be entered. This information is necessary for interpretation of NBS results, if this field is incomplete, the screening results will be reported as inconclusive.
9. Baby Hispanic?:
Indicate whether the baby is of Hispanic ethnicity by marking yes or no. Ethnicity information should be obtained from the birth parents.
Indicate the baby’s racial background by marking all races that apply. Racial information should be obtained from the birth parents.
11. Red Blood Cell Transfusion:
Indicate whether the baby has received a red blood cell (RBC) transfusion prior to NBS specimen collection by marking “yes” or “no.” If the transfusion status is unknown, then leave this field blank. If the baby has been transfused, fill in the date and time of the last transfusion prior to collection of NBS specimen. Transfusion includes “intrauterine” transfusion. This information is necessary for interpretation of NBS results; inaccurate or incomplete information in these fields can result in erroneous screening results. Note about transfusion and NBS: Transfusion affects the results of some NBS tests. Please make an attempt to collect a pre-transfusion NBS specimen even if the baby is less than 24 hours of age. If a baby has been transfused, the NBS specimen should not be collected until 24 hours post-transfusion.
Indicate all types of feedings the baby has received up to 48 hours prior to the collection of the NBS specimen. If the baby is NPO for any reason, please note it on the card in the proper field.
Note about TPN and NBS: Total parenteral nutrition (TPN) and fortified formulas can artificially elevate amino acid levels on NBS testing. An attempt should be made to collect a pre-TPN specimen if the baby is greater than 24 hour old when TPN is initiated. If a baby is on TPN at the time of NBS specimen collection, a repeat NBS may need to be drawn at least 3 hours after TPN is discontinued.
13. Baby in NICU?:
Indicate whether the baby is in the NICU or requires special medical care at the time of NBS specimen collection.
14. Adoption in Process?:
Indicate whether the baby is in the process of being adopted and will not be in the custody of the birth mother at time of NBS follow-up.
15. Check if Parent/Guardian has refused Krabbe Screening
Complete line 15 only if the parents refuse Krabbe Screening.
Birth Mother/Legal Guardian Information
If infant will not be discharged to the birth mother, enter the information for the legal guardian caring for the infant after discharge.
16. Mother’s Name/Legal Guardian’s Name:
Mom Last Name: Enter the last name of the birth mother or legal guardian as it will appear on the baby’s birth certificate.
Mom First Name: Enter the first name of the birth mother or legal guardian as it will appear on the birth certificate.
17. Mother’s/Legal Guardian’s Address:
Mom Address: Enter the street address, including apartment/lot number or PO Box for the birth mother or legal guardian.
City and State: Enter the city, two-letter state abbreviation, Zip Code and four-letter county abbreviation for the birth mother or legal guardian’s address.
Mom Phone #: Enter the mother’s home or cell phone number or an emergency number of a person who can contact mother.
Baby’s Primary Medical Care Provider for Medical Follow-up
18. Med Provider Last/First:
Enter the last name and first name of the primary medical provider who will be providing neonatal care. For infants discharged home in the first week of life, this would be the medical home. For infants remaining in-house past the first week of life, this would be the attending physician.
19. Practice Name:
Enter the name of the medical practice or clinic where the baby will receive neonatal medical care. For infants discharged home in the first week of life, this would be the medical home. For infants remaining in-house past the first week of life, this would be the NICU or other special care unit.
20. Provider Address:
Enter the address, phone and fax number of the medical provider where the baby will receive neonatal medical care. If the complete information is unknown, enter as much information as is available. Throughout the state there are many physicians who have the same name. It is important for the lab to know at least the street and city where the medical practice is located.
21. Provider Telephone/FAX Number:
Enter the telephone number and the fax number for the medical provider where the baby will receive neonatal medical care.
Birth Facility information:
22. Birth Facility Name:
Enter the name of the facility where the baby was born. (Please do not use abbreviations.) If the baby was born outside a hospital or birth center, enter “home” or “other.”
23. Medical Attendant Last / First Name:
Enter the name (Last, First) of the medical provider or midwife attending the baby at birth.
24. Specimen Type:
Indicate whether the current specimen is the baby’s initial specimen or a repeat screen.
25. Collecting Facility:
Enter the name of the facility collecting the NBS specimen. For most infants the collecting facility is the birth facility. If a baby has been transferred from the birth facility, enter the name of the facility where the specimen was collected.
26. Collect Date and Time:
Enter the date and time of specimen collection (use military time: noon = 1200, midnight = 0000). This information is necessary for interpretation of NBS result, if these fields are incomplete the screening results will be reported as inconclusive.
27. Collector’s Initials:
Enter the initials of the individual collecting the specimen.