Welcome to the State of California 

California Newborn Screening Program

Test Request Form (TRF)

Information about the newborn, recorded on the Test Request Form (TRF), is very important for the following reasons:

1. California averages 1,500 births a day. The demographics provide the means for locating a specific infant in order to obtain another specimen for testing whenever the initial specimen:

            a)  is initially positive,

            b)  is inadequate for testing, or

            c)  has an anomalous test pattern.

2. The patient information is used in reporting results to the hospitals and the physicians.

3. Information about a specimen, the birth weight, and transfusion status is used in evaluating the test results. (Note that the transfusion box should be marked "yes" if the newborn had an intrauterine transfusion.)

4. The physician's identity is essential to ensure timely tracking of the infant for follow-up testing and initiation of therapy for a newborn with one of these congenital conditions. The AAP has recommended every newborn have a medical home, i.e., a personal physician assigned at birth.

It is the responsibility of the pediatric provider to ensure the hospital has and is using current address, and that the physician listed on the form is the one providing care after discharge.

The top sheet of the Test Request Form (TRF) provides instructions for filling out the form. It is to be read and discarded.

The TRF should be completely filled out and the specimen collection card should be completed.  The form should be filled out legibly, in capital letters and in blue or black ink. There should be no staples, tape or paper clips and all info should be double checked before being submitted. Failure to double check may lead to an inadequate specimen, the delay from which may put the baby's life at great risk. 

The information on the specimen collection card MUST match the information on the TRF for a specimen to be considered adequate for testing. The newborn’s blood is collected on the specimen collection card. 

The goldenrod copy is detached and remains in the birthing facility. It should be filed in the newborn’s chart. This copy is used for reference and/or tracking purposes and is an essential part of the review process that is conducted 14 days after the specimen is collected. When results are not yet in the newborn’s chart, the goldenrod copy can provide information to be used for tracking the specimen.

The white copy of the TRF, along with the specimen collection card, is sent to the facility's assigned Newborn and Prenatal Screening laboratory. The original white copy must remain attached, yellow copy goes into the NB chart, pink copy to NB parents. A detached white will be viewed as inadequate - if it becomes detached prior to sending it to the testing lab, fill in baby's name and birthdate on lines on filter paper and staple filter paper to the bottom of white page (note: this is the only time you can ever use staples on these forms).  

Completing the Demographic Information on the TRF

CHECK THE EXPIRATION DATE ON THE FORMThe expiration information is in the lower right hand corner of the TRF:

Example: LOT XXXXXX/XXXXX2015-02 (the expiration year is 2015, and the expiration month is 02) - do not use as of the FIRST DAY of the expiration month.

A specimen collected on an expired form will be deemed inadequate and the screen will need to be redone, thus delaying test results.

Accuracy and completeness of all the information provided about the newborn is very important for several reasons:

  • The date and time of birth, birthweight, date and time of specimen collection, and information on transfusion status, are all critical for evaluating the newborn screening results.
  • NBS results are sent to the physician of record as listed on the TRF. Incorrect or incomplete physician information delays or prevents receipt of the mailer or contacting the physician by phone, thereby potentially delaying timely follow-up.
  • Should follow-up be needed on a newborn who has already been discharged, the newborn’s complete address is necessary for locating the infant.

Complete each field as follows:

Baby's info

  • Write the baby's name as entered on the birth certificate.
  • Enter address info entirely, there are now bigger fields to fit it all.
  • Put the baby's last name first, the real and full name of the baby is always better than "Baby Boy Smith".
  • If there are multiple births, indicate birth A, B or C in the appropriate box.

Mother's Info

  • For the mother's info, enter mother's last name, first name and middle inital
  • Enter the mother's birth date.
  • Enter the last four digits of the mother's social security number. **If she has no social security number enter 9999**
  • Write mother's maiden name.
  • Write mother's phone number and alternate phone number, make sure these are numbers at which the mother can truly be reached
  • If the mother is not the legal guardian (in case of surrogacy or a same sex couple) list the person who has custody of the baby

Ward of the court

  • If the baby is a ward of the court - check that box
  • Document contact info for the baby who is a ward of the court keeping in mind we need to find the best way to track down that baby
  • The contact person may be a case worker

Newborn's physician info

  • Physicians info should not be the hospital MD - needs to be the physician the baby will see after discharge - the one responsible for the baby
  • List the physician's complete address and phone number
  • List the complete license number of the physician

Race/ethnicity and language

  • Race and ethcnicity data are not used for follow-up but are useful for profiling disorders and gene variations by ehthnicity
  • Use the parents self-identification for ethnicity and fill in all that apply
  • Indicate primary language - this is important for follow-up so an interpreter can be available. People will often not pick up after the first phone call

Facility info

  • For the facility info, indicate accurate name and submitter code - double check this info - if the wrong facility is sent the specimen, it violates HIPAA and delays the baby getting care - there is a 14 day chart audit on every specimen sent out - they will wonder where it went
  • Include the initials of the person drawing the specimen

Bottom of form - left side

  • Fill in birth date and military time of birth - if it is midnight, it makes the form ambiguous as to which is the birthdate so list 23:59 or 00:01 (note: 00:00 will not be taken by the  system)
  • Birthweight should be listed in grams not pounds - it is used to determine the cutoffs for disorders - and listing pounds delays the screen as the lab has to contact the ASC, which then contacts the hospital to find out weight in grams
  • FIll in the sex of the baby
  • Fill in gestational age at delivery - this is a new field - round to the nearest whole number
  • Nursery type has been changed to include home births. Other would be filled in with "taxicab" or some other location not listed
  • There is a change in the nutrition info - was the baby NPO at the time of the specimen collection?
  • The feedings since birth section has no effect on the NBS result, but generates breast feeding statistics
  • TPN - Y or N - this is important and is one of the most missed fields on the TRF - it must be filled out

Bottom of form - right side

  • Specimen collection time - again use miltary time and avoid using 24:00 or 00:00
  • Type of specimen is important - screening is calibrated using heel stick blood, but premature babies may have their specimens drawn from a line
  • Reason for test field also important - initial, other, repeat, etc.
  • Transfusion info - If the specimen is collected after a transfusion, it will invalidate hemoglobin and galactosemia results. This field is the most missed, but important for hospital performance data
  • If mom is leaving the hospital early, often a collection is taken before 12 hours - it is important to indicate this as the specimen will have to be re-drawn if collected before 12 hours

Bottom of TRF

  • Bottom left hand side - fill in the unique identifier for that baby at the hospital - Medical record number/identifier
  • Bottom right hand side - hospital order number - leave it blank, will be used in the future
 
 
Last modified on: 7/26/2012 1:54 PM