"Environmental Samples Submission Form - Biological" - Hawaii

Environmental Samples Submission Form - Biological is a legal document that was released by the Hawaii Department of Health - a government authority operating within Hawaii.

Form Details:

  • The latest edition currently provided by the Hawaii Department of Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Hawaii Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download "Environmental Samples Submission Form - Biological" - Hawaii

118 times
Rate (4.7 / 5) 6 votes
State Laboratories Division
Laboratory Preparedness and Response Program
Biological Response Section
Rebecca H. Sciulli, LPRP Manager
Ph: (808) 453-5993 & 453-5994; Cell: (808) 368-3373; Fax: (808) 453-5995
ENVIRONMENTAL SAMPLES SUBMISSION FORM – BIOLOGICAL
To Be completed by the Biological Response Section Staff
Submitters ID No.:
_____________________
Lab Accession Number:
Other ID Number:
To Be completed by the Responding Agency
Case Number:
Sample Collection Date:
_____/_____/_____
County:
Sample Collection Time:
______ AM PM
Reporting Citizen:
Direct Telephone #:
Incident Address:
HI
ZIP
Article Opened:
Yes
No
Unknown
Article description:
Powder
Letter/Envelope
Swab
Other:
Number of Individuals Exposed:
Names of Individuals Exposed:
Yes
No
Building closed due to incident:
Package exterior was decontaminated:
Yes
No
Sample tested for explosive agent:
Yes
No
Yes
No
Yes
No
Sample tested for chemical agent:
Sample tested for radiological agent:
Responding Agency: ______________________________ Package delivered by: _______________________
Cellular Number: _______________ Work Number: _____________________ Fax Number: ______________
Agency Address: ________________________________________________________ HI ZIP ____________
Incident Description: _________________________________________________________________________
__________________________________________________________________________________________
Signature:
________________________________
Date: _____/_____/_____ Time: _________ AM PM
NOTE: Sample will be discarded 30 days after testing unless otherwise instructed
To Be completed by the Biological Response Section Staff
Received by: ________________________________
Date: _____/_____/_____ Time: _________ AM PM
Signature:
________________________________
Specimen forwarded to:
Centers for Disease Control and Prevention (
)
Director, Bacterial Special Pathogens Branch - Zoonoes and Select Agent Laboratory
Other:
________________________________
Signature:
________________________________
Date: _____/_____/_____ Time: _________ AM PM
LPRP_BRS_FRM_Environ-Sample-Submission_6v3
Page 1 of 4
State Laboratories Division
Laboratory Preparedness and Response Program
Biological Response Section
Rebecca H. Sciulli, LPRP Manager
Ph: (808) 453-5993 & 453-5994; Cell: (808) 368-3373; Fax: (808) 453-5995
ENVIRONMENTAL SAMPLES SUBMISSION FORM – BIOLOGICAL
To Be completed by the Biological Response Section Staff
Submitters ID No.:
_____________________
Lab Accession Number:
Other ID Number:
To Be completed by the Responding Agency
Case Number:
Sample Collection Date:
_____/_____/_____
County:
Sample Collection Time:
______ AM PM
Reporting Citizen:
Direct Telephone #:
Incident Address:
HI
ZIP
Article Opened:
Yes
No
Unknown
Article description:
Powder
Letter/Envelope
Swab
Other:
Number of Individuals Exposed:
Names of Individuals Exposed:
Yes
No
Building closed due to incident:
Package exterior was decontaminated:
Yes
No
Sample tested for explosive agent:
Yes
No
Yes
No
Yes
No
Sample tested for chemical agent:
Sample tested for radiological agent:
Responding Agency: ______________________________ Package delivered by: _______________________
Cellular Number: _______________ Work Number: _____________________ Fax Number: ______________
Agency Address: ________________________________________________________ HI ZIP ____________
Incident Description: _________________________________________________________________________
__________________________________________________________________________________________
Signature:
________________________________
Date: _____/_____/_____ Time: _________ AM PM
NOTE: Sample will be discarded 30 days after testing unless otherwise instructed
To Be completed by the Biological Response Section Staff
Received by: ________________________________
Date: _____/_____/_____ Time: _________ AM PM
Signature:
________________________________
Specimen forwarded to:
Centers for Disease Control and Prevention (
)
Director, Bacterial Special Pathogens Branch - Zoonoes and Select Agent Laboratory
Other:
________________________________
Signature:
________________________________
Date: _____/_____/_____ Time: _________ AM PM
LPRP_BRS_FRM_Environ-Sample-Submission_6v3
Page 1 of 4
State Laboratories Division
Laboratory Preparedness and Response Program
Biological Response Section
Rebecca H. Sciulli, LPRP Manager
Ph: (808) 453-5993 & 453-5994; Cell: (808) 368-3373; Fax: (808) 453-5995
Instructions for Completing
ENVIRONMENTAL SAMPLES SUBMISSION FORM – BIOLOGICAL
Case Number:
Law Enforcement Agency or Fire & HAZMAT case number.
County:
The county where the sample was collected.
Sample Collection Date:
The date the sample was collected.
Sample Collection Time:
The time the sample was collected.
Reporting Citizen:
The citizen who reported the incident.
The citizen’s home or work phone number or other (cell phone)
Direct Telephone #:
Incident Address:
The location where the sample was collected.
A description of the item found by a citizen.
Article description:
Please check the word which best describes the sample
(i.e. Powder, Letter/Envelope, Swab, Other).
Article Opened:
If the article is a suspicious envelope, package, etc. was it opened?
Number of persons present in the immediate vicinity of the suspect
Number of Individuals Exposed:
material.
Names of persons present in the immediate vicinity of the suspect
Names of Individuals Exposed:
material.
Building closed due to incident:
Is the building closed to limit exposure to the suspect material?
Name of Law Enforcement Agency, Fire & HAZMAT or Department of
Responding Agency:
Public Safety.
Package delivered by:
Name of representative from Responding Agency.
Cellular / Work / Fax Number:
Contact information for Responding Agency.
Agency Address:
Address of the agency submitting the sample.
Incident Description:
Brief description of the incident.
Signature / Date / Time:
Signature of representative from Responding Agency for chain-of-custody.
NOTE: Sample will be discarded 30 days after testing unless otherwise instructed.
LPRP_BRS_FRM_Environ-Sample-Submission_6v3
Page 2 of 4
State Laboratories Division
Laboratory Preparedness and Response Program
Biological Response Section
Rebecca H. Sciulli, LPRP Manager
Ph: (808) 453-5993 & 453-5994; Cell: (808) 368-3373; Fax: (808) 453-5995
Instructions for Submitting Samples for Biological Agent Testing
Environmental Samples:
1. Will be accepted by the Biological Response Section only after FIRE / HAZMAT Responders have
performed their assessment to rule out radiological, explosive and chemical agents.
2. Only suspected samples such as swabs, powder, contaminated paper, letters or liquid shall be
submitted for testing. Samples should be double-bagged and put in a container no larger than
necessary and should not exceed one gallon in size. Sample submission form must be completed and
securely attached. (Please refer to: Protocols for Transporting Specimens to the Biological Response
Section.)
3. Extraneous materials such as gloves, towels, and clothing MUST NOT be included with the samples.
Extraneous materials should be placed in a biohazard bag and disposed of locally according to state
and federal guidelines.
4. Please refer to Attachment “A” for Decontamination procedures for containers with sample.
LPRP_BRS_FRM_Environ-Sample-Submission_6v3
Page 3 of 4
State Laboratories Division
Laboratory Preparedness and Response Program
Biological Response Section
Rebecca H. Sciulli, LPRP Manager
Ph: (808) 453-5993 & 453-5994; Cell: (808) 368-3373; Fax: (808) 453-5995
DECONTAMINATION PROCEDURES
FOR CONTAINERS WITH SAMPLES
Containers containing samples shall be decontaminated with a freshly
made bleach solution prior to leaving the sampling area.
To make a fresh bleach solution mix 1 cup of household bleach
(8.25% sodium hypochlorite) with 13 cups of water.
1. Spray sample jars with the bleach solution and allow jars to sit for
ten minutes before transporting to the hazard categorization
(HazCat) area.
2. Wipe down the sample jar with an absorbent material.
3. After the HazCat has been completed and a determination has
been made to transport the sample, place the sample in a plastic
bag (Bag 1) and seal it.
4. If the sample is to be transported to the State Laboratories
Division for biological analysis:
Spray the outside of the sealed bag 1 with the bleach
a.
solution.
b. Place the sealed bag 1 in a plastic bag 2 (Bag 2) and seal it.
c. Transfer the sealed bag out of the hot zone.
Place the sealed sample bag (Bag 2) in a biohazard bag
d.
(Bag 3).
Or,
If the sample is to be transported to the University of Hawai’i for
chemical analysis:
a. Place the sealed bag 1 in a plastic bag 2 (Bag 2) and seal it.
b. Transfer the sealed bag out of the hot zone.
LPRP_BRS_FRM_Environ-Sample-Submission_6v3
Page 4 of 4
Page of 4