New Jersey Department of Health

NEWBORN SCREENING PROGRAM

P.O. BOX 371, Trenton, NJ 08625-0371

SPECIMENS FOR

NEWBORN BIOCHEMICAL SCREENING

Please print or type.	✃	New Jersey Department of Health

NEWBORN SCREENING PROGRAM

P.O. BOX 371, Trenton, NJ 08625-0371

SPECIMENS FOR

NEWBORN BIOCHEMICAL SCREENING

Please print or type.
Date Submitted

Date Submitted

Submitted By

Submitted By

City

City

UPS Tracking Number

UPS Tracking Number

Submitter’s

ID Number	Last Name / Gender	Birthdate
Submitter’s

ID Number	Last Name / Gender	Birthdate
1
1
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2
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3
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5
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FOR STATE USE ONLY
FOR STATE USE ONLY
Specimens Verified By (Initials/Date)
Specimens Verified By (Initials/Date)
IEM-3

DEC 12	SUBMIT WITH SPECIMENS	✃	IEM-3

DEC 12	HOSPITAL COPY

IEM-3, Specimens for Newborn Biochemical Screening

Newborn screening program, IEM-3, specimens for Newborn Biochemical Screening, laboratory, philep, phel, iem, nbs,

ewhite

2012-04-19

NJDOH