S.C. Code Regs. 61-80.C - Blood Sample Storage Options Form: DHEC 1812, Blood Sample Storage Options, Screening for Inborn Metabolic Errors and Hemoglobinopathies

Child's complete legal name: __________

Child's date of birth: __________

Parent or legal guardian's complete name: __________

Parent or legal guardian's complete address: __________

South Carolina law requires the Department of Health and Environmental Control to store your child's blood sample in a manner required by law. The blood sample is collected on a special piece of filter paper. This is called "newborn screening." The blood is tested to see if your child has one of the "newborn screening" diseases that can cause intellectual disability, abnormal growth or even death. After the tests are done, the filter paper is stored in a freezer at the state laboratory. This storage is highly protected, and each sample is held under strict confidentiality. A child's blood sample can only be released for approved research, without any identifying information, to learn new information about diseases. The law allows you to choose one of the options below, if you do not want your child's blood sample handled this way. However, you are not required to check one of the boxes below.

[ ] I want my child's blood sample stored by the South Carolina Department of Health and Environmental Control, but I do not want my child's blood sample to be used for research.

[ ] I want my child's blood sample destroyed by the South Carolina Department of Health and Environmental Control two years after the date of testing.

[ ] I want my child's blood sample to be returned to me two years after the date of testing. I understand that it is my responsibility to notify the South Carolina Department of Health and Environmental Control, 2600 Bull Street, Columbia, SC, 29201, of address or name changes.

I have been given the brochure produced by the South Carolina Department of Health and Environmental Control that describes the conditions for which testing is currently available and explains the benefits of testing and blood sample storage.

Parent: __________ Date: __________

I have given the brochure produced by the South Carolina Department of Health and Environmental Control to the parent/legal guardian of the child named above.

Name: __________ Date: __________

DHEC can store your baby's blood sample for special study. Studies help DHEC find out new information about diseases. If a study finds something in your child's blood sample that can help your child, DHEC can confidentially notify you (or your child if he/she is 18 years or older).

IF THIS FORM IS NOT SIGNED BY A PARENT/LEGAL GUARDIAN AND/OR NONE OF THE ABOVE BOXES ARE CHECKED, THE BLOOD SAMPLE WILL BE STORED AS REQUIRED BY SC CODE ANN. Section 44-37-30 AT -20 DEGREES CENTIGRADE AND MAY BE RELEASED ONLY FOR CONFIDENTIAL, ANONYMOUS SCIENTIFIC STUDY.

NOTE TO PROVIDERS: The parent or legal guardian is not required to sign this form. However, the person who gives the brochure that explains neonatal testing and blood sample storage to the parent or legal guardian must sign this form.

Notes

S.C. Code Regs. 61-80.C

Added by State Register Volume 3, Issue No. 7, eff July 13, 1979. Amended by State Register Volume 13, Issue No. 3, eff March 24, 1989; State Register Volume 27, Issue No. 6, Part 1, eff June 27, 2003.