Free VA Form 10-9009f - Depleted Uranium (DU) Program Checklist - Federal

DEPLETED URANIUM (DU) PROGRAM CHECKLIST 24-HOUR URINE URANIUM COLLECTION BALTIMORE VA MARYLAND HEALTH CARE SYSTEM
CONSULT URINE INSTRUCTIONS (REVISED 07/98) 1. PATIENT NAME 2. SOCIAL SECURITY NUMBER

3. ADDRESS

4. SPECIMEN DATE

5. TELEPHONE NUMBER

6. DATE OF BIRTH

7. REFERRING VA MEDICAL CENTER AND ADDRESS

8. MAIL CODE

9. REFERRING PHYSICIAN

10. PAGER NUMBER

11. TELEPHONE NUMBER

12. FAX NUMBER (To receive report)

13. REFERRING FACILTY CONTACT NAME

14. REFERRING FACILITY CONTACT PHONE NUMBER

Call the DU Program at 1-800-815-7533 to obtain the specimen collection kits. Each kit includes shipping materials and eight 500 ml containers to be used for the collection of urine over a 24 hour period. The materials in the kits conform to shipping regulations #173.199 and FEDEX shipping requirement (IATA Packing Instruction 650). The shipper of the diagnostic specimens assumes responsibility for complying with these shipping requirements. Using bottles and packing materials supplied by the DU Program, and using them according to directions, assures compliance.
Schedule patient for 24-hour urine collection.
DATE A. TIME OF FIRST VOID (DISCARDED) URINE DAY 1 B. TIME OF FIRST VOID URINE DAY 2

Instruct the patient to urinate directly into the collection container(s), filling each container before proceeding to the next. Uranium sticks to the sides of the container. Therefore, do not transfer urine due to potential loss of analyte. Issue 8 containers to patient to ensure full 24-hour collection in approved containers. Instruct the patient to collect urine beginning after first morning void of Day 1 and end collection after first morning void on Day 2 (the next day). Seal containers as tightly as possible. Bag each urine container with absorbent material. Make sure each plastic bag is sealed tightly. The sample must be mailed in the package provided. TIP: CONTACT YOUR LABORATORY SERVICES SUPERVISOR TO ASSIST IN PACKAGING. SEND SPECIMEN VIA FEDEX.

FEDEX TRACKING NUMBER: SEND TO:

VA MARYLAND HEALTH CARE SYSTEM PATHOLOGY AND LABORATORY MEDICINE SERVICE (113) 10 N. GREENE STREET BALTIMORE, MARYLAND 21201 ATTN: CHEM. LAB (113) (FOR DU PROGRAM)
This completed VA Form 10-9009F and the completed copy of VA Form 10-9009D must be faxed to the DU office at 410-605-7943 before sending the urine sample. Another copy of this VA Form 10-9009F, sealed in a Ziploc bag, must be enclosed with the sample for identification purposes. Notification of the results can be expected in approximately 90 days.
VA FORM DEC 2007

10-9009F