RESIDUAL NEWBORN SCREENING BLOOD SPOT DIRECTIVE
Michigan Department of Health and Human Services
Child’s Name at Birth	Date of Birth
Child’s Current Name	Check Birth Order if Multiple Birth
1st	2nd	3rd	4th	5th
Mother’s Name at Time of Child’s Birth	Hospital of Birth
I am a legal representative* of the child named above. I am asking the Michigan Department of Health and Human Services (MDHHS) to (check one):
Destroy all remaining blood spots. I understand that by checking this box, NO blood spots will be available for any future use including medical, identification, or research purposes.
Destroy only the portion of blood spots stored for research use. I understand by checking this box, one blood spot will be held by MDHHS. I must direct any potential future use including medical, identification or research purposes.
Store but not use blood spots for research after newborn screening is complete. I understand that the blood spots will be kept by the laboratory but not used for research of any kind unless directed in writing by me.
* Legal representative means a parent or guardian of a minor who has authority to act on behalf of the minor or the individual from whom the specimen was collected if 18 years or older or legally emancipated.
Signature of parent, guardian or other legal representative	Relationship to Child
Printed Name	Date
Street Address	City	Zip Code	Phone Number
If you are asking MDHHS to destroy any blood spots, you must also attach a copy of the birth certificate belonging to the person whose blood spots are being destroyed AND the driver’s license, state issued identification card or passport of the person who signed above.

Return document(s) via:

Email: biotrust@michigan.gov	Fax: 517-335-9419	or

Post Mail: BioTrust Coordinator, NBS Follow-up Program, PO Box 30195, Lansing, MI 48909
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.	Authority: Michigan Public Health Code, Act 368 of 1978

MDHHS-5683 (1-18)

Residual Newborn Screening Blood Spot Directive

Genomics and Genetic Disorders

2018-01-10

Karasinski, Kristy (DHHS-Contractor)

Michigan Department of Health and Human Services