Delaware Public Health Laboratory
Chemical Preparedness Clinical
Specimen Shipping Manifest

PAGE ___ OF ___

DIRECTIONS:  Complete and place this form in a ziploc plastic bag between the secondary and outer container of the
shipping container. Use one form per box of samples. Complete DPHL "Chain of Custody Form for Clinical Preparedness 
Samples" for EACH sample batch. Complete DPHL "Chain of Custody Form for Clinical Preparedness Samples" for each sample.



DATE SHIPPED:_____________________________________ 

SHIPPED BY:_______________________________________ 

CONTACT TELEPHONE:_____________________________ 

SIGNATURE:_______________________________________


DATE RECEIVED:___________________________________ 

RECEIVED BY:______________________________________ 

SIGNATURE:________________________________________


TOTAL NUMBER OF SPECIMENS IN THIS CONTAINER:	SPECIMEN TYPE (specify): ______________________________

						SPECIMEN TYPE (specify): ______________________________

						SPECIMEN TYPE (specify): ______________________________

						SPECIMEN TYPE (specify): ______________________________

						SPECIMEN TYPE (specify): ______________________________

						SPECIMEN TYPE (specify): ______________________________


COMMENTS: _____________________________________________________________________________________________  

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________


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


DPHL CT Shipping Manifest - Clinical