DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Delaware Public Health Laboratory Chemical Preparedness Specimen Collection And Urine Cup Shipping Manifest PAGE ___ OF ___ DATE SHIPPED:_____________________________________ SHIPPED BY:_______________________________________ CONTACT TELEPHONE:_____________________________ SIGNATURE:_______________________________________ DATE RECEIVED:___________________________________ RECEIVED BY:______________________________________ SIGNATURE:________________________________________ TOTAL NUMBER OF SPECIMENS IN THIS CONTAINER: URINE CUPS: ________________ TOTAL NUMBER OF BLANK URINE CUPS PROVIDED IN THIS CONTAINER: BLANK URINE CUPS: ________________ 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 #35-05-20/07/03/90 DELAWARE HEALTH AND SOCIAL SERVICES Division of Public Health Delaware Public Health Laboratory Chemical Preparedness Specimen Collection And Urine Cup Shipping Manifest PAGE ___ OF ___ PLEASE INDICATE THE AMOUNT OF URINE COLLECTED IN THE UC COLUMN UC = URINE CUP Patient/Victim UC Patient Signs & Symptoms ID Label (Amount) (include rating 10 worst, 1 none) Comments: _______________________ ____________ _________________________________________________ _________________________________________________ _________________________________________________ _______________________ ____________ _________________________________________________ _________________________________________________ _________________________________________________ _______________________ ____________ _________________________________________________ _________________________________________________ _________________________________________________ _______________________ ____________ __________________________________________________ __________________________________________________ __________________________________________________ _______________________ ____________ __________________________________________________ __________________________________________________ __________________________________________________ NOTE:Please include 2 empty urine cups from each lot number collected for background contamination measurement. Doc #35-05-20/07/03/90