South Carolina Code of Regulations › Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL › Subchapter 61-80 - Neonatal Screening For Inborn Metabolic Errors and Hemoglobinopathies › Appendix 61-80.C - Blood Sample Storage Options Form: DHEC 1812, Blood Sample Storage Options, Screening for Inborn Metabolic Errors and Hemoglobinopathies

Current through Register Vol. 48, No. 6, June 28, 2024
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.