Request for Neutrophil Laboratory Services - Red Cross Blood



439058414550Neutrophil Laboratory Use OnlyDate: ____________Time: _______ Initials: _______Condition: _______________ Stored: ___________Accession # 00Neutrophil Laboratory Use OnlyDate: ____________Time: _______ Initials: _______Condition: _______________ Stored: ___________Accession # American Red Cross - National Neutrophil LaboratoryMinnesota - Dakotas Region, St. Paul, MN Phone: (651) 291-6797 - Local (855) 216-9202 – Toll-FreeFax: (651) 291-3233Website: page 2 for instructions, sample types, labeling and shipping requirementsPatient/Donor Information:Name _________________________________Age/DOB _________Patient ID/MR#/DID _______________________________________S/O DIN: _______________________ Gender: male ___ female ___Institution _______________________________________________Department/Address ______________________________________City/State/ZIP____________________________________________Contact Name _____________________ Phone _______________E-Mail ___________________________ Fax __________________Specimen Information:Collection date _______________________Specimen type (check one) _____ Serum_____ Plasma (anticoagulant type) ___________Physician ____________________________Reports: _____E-Mail _______FaxClinical Conditions: ___ Autoimmune Neutropenia___ Alloimmune Neonatal Neutropenia___ Drug Dependent Neutrophil Antibody___ Diagnosis UnspecifiedChoose test(s) from list belowTRALI Investigation: (Transfusion-Related Acute Lung Injury) *Please specify Donor or Recipient____ Donor____ RecipientChoose test(s) from list belowTest Requests:Recommended Testing - Clinical Neutropenia:___ Neutrophil Antibody IdentificationAdditional Specialized Testing:___ MAINA (Monoclonal Antibody Immobilization of Neutrophil Antigens)___ Neutrophil Crossmatch___ Drug Dependent Neutrophil Antibody___ HLA Class I antibody screen___ HNA Phenotyping (HNA-1a, 1b, 1c, 2, 3a, & 4a)HNA Genotyping (Select all that apply)____ HNA-1a/1b/1c ____ HNA-3a/3b____ HNA-4a/4b____ HNA-5a/5bwTest Requests: Recommended Testing – TRALI Investigation:____ Neutrophil Antibody Identification -and-HLA Class I and Class II Antibody____ Screen + Single Antigen ID (if screen is positive)Additional Specialized Testing:___ MAINA (differentiation of HNA antibodies from HLA Class I antibodies)___ Neutrophil Crossmatch___ HNA Phenotyping (HNA-1a, 1b, 1c, 2, 3a, & 4a)HNA Genotyping (Select all that apply)__ HNA-1a/1b/1c __ HNA-3a/3b __ HNA-4a/4b __ HNA-5a/5bwInstructions to submit samples for neutrophil testing:1. Refer to the table below for specimen and handling requirements for each test.2. Label each vial with the patient’s name or donation identification number (DIN), a second identifier (DOB, Medical Record Number or DID) and the collection date.3. Complete Page 1 of this form and include it with each specimen vial.4. Refer to table below for shipping requirements. Specimens must be shipped following federal and local requirements for shipping biological substances, category B. Shipping Address:National Neutrophil LaboratoryBusiness Hours:8:00 AM – 4:30 PM Mon-FriMinnesota-Dakotas RegionPhone:(651) 291-6797 or (855) 216-9202100 South Robert StreetFax:(651) 291-3233St. Paul, MN 55107Website: & Handling RequirementsStorage & Shipping RequirementsNeutrophil Antibody IdentificationMinimum of 500 μL of serum or plasma:Serum from a plain red top tube.Plasma – EDTA or anticoagulant used in donor collection are acceptable. Segments, gel tubes, and PPT tubes are NOT acceptable.Separate plasma and /or serum from red blood cells.Ship frozen on dry ice via overnight courier.If collected < 72 hours, specimens may be shipped refrigerated using ice packs or wet ice.Send samples Mon. - Thurs. to ensure weekday delivery.MAINA(Only performed in conjunction with a Neutrophil Antibody Identification request)Minimum of 500 μL of serum or plasma.(Collection and handling per Neutrophil Antibody Identification requirements).Separate plasma and/or serum from red blood cells. Per Neutrophil Antibody Identification requirements. Send samples Mon. - Thurs. to ensure weekday delivery.HLA Class I and Class II AntibodyMinimum of 1 mL of serum. Serum from a plain red top tube.Separate serum from red blood cells. Ship frozen on dry ice via overnight courier.If collected < 72 hours, specimens may be shipped refrigerated using ice packs or wet ice.Send samples Mon. - Thurs. to ensure weekday delivery.TRALI Work-upMinimum of 2 mL of serum. Serum from a plain red top tube.Separate plasma and/or serum from red blood cells.Per Neutrophil Antibody Identification requirements. Send samples Mon. - Thurs. to ensure weekday delivery.*Drug Dependent Neutrophil Antibody*Call lab (651) 291-6797 before sample collection*Minimum of 500 μL of serum or plasma.(Collection and handling per Neutrophil Antibody Identification requirements).2-5 mg of each drug of interest.Separate plasma and/or serum from red blood cells.Per Neutrophil Antibody Identification requirements. Send samples Mon. - Thurs. to ensure weekday delivery.*Neutrophil Crossmatch*Call lab (651) 291-6797 before sample collection Sample 1. Minimum of 500 μL of serum or plasma (Collection and handling per Neutrophil Antibody Identification requirements).Separate plasma and/or serum from red blood cells.Sample 2. 14 – 28 mL of EDTA whole blood maintained at ambient temperature.DO NOT separate plasma from red blood cells.Sample 1: Serum/plasma. Per Neutrophil Antibody Identification requirements. Sample 2: Neutrophils. Ship at ambient temperature in an insulated container.Must be received within 24 hours. Send samples Mon. - Thurs. to ensure weekday delivery.*HNA Phenotyping(HNA-1a, 1b, 1c, 2, 3a & 4a) *Call lab (651) 291-6797 before sample collection 14 – 28 mL of EDTA whole blood maintained at ambient temperature.DO NOT separate plasma from red blood cells.Ship at ambient temperature in an insulated container. Must be received within 24 hours Send samples Mon. - Thurs. to ensure weekday delivery.*HNA Genotyping*Call lab (651) 291-6797 before sample collection4 or 6 mL of whole blood collected in citrate or EDTA anticoagulant. Store at ambient or refrigerated temperature.DO NOT separate plasma from red blood cells.Ship at ambient or refrigerated using ice packs or wet ice. Send samples Mon-Thurs to ensure weekday delivery. ................
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