Genecord's Collection Worksheet

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1. GENECORD LLC 900 Northern Blvd, Suite 230 Great Neck, NY 11021 877 – 783 – 7836 (available 24/7) Cord Blood Collection Worksheet Hospital Collector to Complete at Collection Collector Printed Name : ______________________ Collector Signature : ______________________ *I certify that the caregiver instructions provided me with the necessary information to collect umbilical cord blood.* Date of Collection : ___________________ Time of Collection : Start : ______________ Finish : ______________ Number of umbilical cord punctures : 1___ 2___ 3___ Unknown ___ ( Ensure puncture sites are disinfected ) Do you have any reason to suspect contamination of the cord blood, e.g., evidence of infection (mother, baby or placenta), significant tears or other problems with cord or placenta, collection difficulty: Yes ___ No ___ Maybe ___ If yes or maybe, please explain in comments . Comments : ________________________________________________________________________ ________________________________________________________________________ _________________________________________ _______________________________ ________________________________________________________________________ ________________________________________________________________________ Check list for collection kit 4 tubes of mother’s blood 1 bag of labeled infant umbilical cord blood This Collection Worksheet

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