DELAWARE HEALTH AND SOCIAL SERVICES
Division of Public Health
Delaware Public Health Laboratory
Chemical Preparedness Specimen Collection
And Blood Tube Shipping Manifest

PAGE ___ OF ___


DATE SHIPPED:_____________________________________ 

SHIPPED BY:_______________________________________ 

CONTACT TELEPHONE:_____________________________ 

SIGNATURE:_______________________________________


DATE RECEIVED:___________________________________ 

RECEIVED BY:______________________________________ 

SIGNATURE:________________________________________



TOTAL NUMBER OF SPECIMENS IN THIS CONTAINER:	PURPLE-TOP TUBES:	________________

						GREEN/GRAY-TOP TUBES:	________________




TOTAL NUMBER OF BLANK TUBES PROVIDED
IN THIS CONTAINER:				PURPLE-TOP TUBES:	________________

						GREEN/GRAY-TOP TUBES:	________________



COMMENTS: _____________________________________________________________________________________________  

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________


SHIPPING ADDRESS:	Delaware Public Health Laboratory
			Attn: Tara Lydick, CT Coordinator 
			30 Sunnyside Road 
			Smyrna, DE 19977 
			(302) 223-1520



COMPLETE SAMPLE LOG AND PATIENT’S SIGNS & SYMPTOMS (NEXT PAGE) 
Doc #35-05-20/07/03/87

DELAWARE HEALTH AND SOCIAL SERVICES
Division of Public Health
Delaware Public Health Laboratory
Chemical Preparedness Specimen Collection
And Blood Tube Shipping Manifest

PAGE ___ OF ___

PLACE A / IN EACH BOX FOR SAMPLES SHIPPED - PLACE AN X IN EACH BOX FOR SAMPLES NOT SHIPPED.

PLEASE INDICATE THE SIZE TUBE COLLECTED (5 OR 7 ml) IN THE COMMENTS.

PT= PURPLE-TOP		GT=GREEN/GRAY-TOP  


Patient/Victim		  	PT 1  PT 2  PT 3  GT	Patient Signs & Symptoms 
ID Label						(include rating 10 worst, 1 none)
							Comments:  

_______________________		____  ____  ____  ___	_________________________________________________

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_______________________		____  ____  ____  ___	_________________________________________________

							_________________________________________________

							_________________________________________________



_______________________		____  ____  ____  ___	_________________________________________________

							_________________________________________________

							_________________________________________________



_______________________		____  ____  ____  ___	__________________________________________________

							__________________________________________________

							__________________________________________________


_______________________		____  ____  ____  ___	__________________________________________________

							__________________________________________________

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NOTE:Please include 2 empty purple-top tubes and 2 empty green/gray-top tubes from each lot number collected 
for background contamination measurement.

Doc #35-05-20/07/03/87