Chemical Terrorism Packaging and Shipping Just...check to see if urines are frozen. q Assemble packaging materials – see next page for list of materials needed to package 10 adult

Judith M. Persichilli, RN, BSN, MACommissioner

Judith M. Persichilli, RN, BSN, MAPhil Murphy, GovernorSheila Y. Oliver, Lt. Governor

Phil Murphy,y,y Govevev rnrnr orila Y Oliver Lt Govevev rnrnr

Chemical TerrorismPackaging and Shipping

August 2020

Important Addresses ...............................ii

Preface....................................................iii

Recognition of a Chemical Terrorism Event........................................................1

Get Dry Ice...............................................2

Prepare Labels .........................................3

Collect and Label Specimens...................4

Specimen Conditioning........................... 6

Pre-packaging Checklist ......................... 8

List of Materials.......................................9

Packaging Frozen Urines .......................11

Packaging Refrigerated Blood ...............20

Driver Instruction and Sample Chain of Custody ...................................34

Directions to Public Health Laboratory, West Trenton, NJ ................35

References .............................................37

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Chemical Terrorism: Packaging and Shipping

Table of Contents

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Just-In-Time Training Manual

New Jersey Public Health,Environmental and AgriculturalLaboratories (PHEAL)3 Schwarzkopf Dr.,Ewing, NJ 08628Attention: Shawn O’Leary609-508-7417

(Located on the grounds of the New Jersey State Police Headquarters Complex)

Centers for Disease Control andPreventionAttn: Chariety Sapp4770 Buford Hwy.Building 110 Loading dockAtlanta, GA 30341(770)-488-0343(770)-488-4600

ImportantAddresses

The Laboratory Response Network (LRN) is anarticulated network of local, state and federallaboratories prepared to work together in a rapidresponse during a bioterrorism or chemicalterrorism event. Hospital laboratories are part ofthe LRN.

In a chemical terrorism event, when patients whomay have been exposed to chemical agents, areexpected to present in hospital emergencydepartments, the hospital laboratory should beprepared to respond by:

1. Rapidly collecting appropriate specimens

2. Rapidly conditioning specimens at appropriatetemperatures

3. Packaging and shipping specimens as Biologicalsubstances, Category B, according to:

v USDOT 49 CFR 173.199 packaginginstruction

v Manufacturer’s instructions for qualifiedshipping systems

v Centers for Disease Control and Prevention(CDC) guidance

4. Completing appropriate shipping manifests andchain of custody documents

5. If requested, transporting packages to the New Jersey Public Health Laboratory

This manual has been designed as a Just-In-TimeTraining Guide for hospital laboratories in carryingout these responsibilities. Packaging requirementsfrom CDC, USDOT and the manufacturer of thequalified shipping system, Timesaver 48, havebeen integrated to simplify the user’s process.

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Preface

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Before an event occurs:

1. Procure, secure and regularly inventorymaterials listed in this manual on page 9-10.

2. Pre-condition the cold packs in theTimeSaver 48 shipping systemaccording to the manufacturer’sinstructions.

Note: for each blood box shipped, youwill need 10 refrigerated gel packs and 4 frozen gel packs.

3. Identify and maintain a dry ice vendor forshipment of urine.

4. Have NJDOH contact information anddirections available in the laboratory.

5. Have a hospital chain of custody formprepared and available to accompanyshipment.

6. Pre-print urine and blood shippingmanifests.

7. Train and review training periodicallywith all responsible staff.

Be Prepared

v


New Jersey Department of HealthPHEL/ECLS/CT Program..............1-609-508-7417

New Jersey Poison Control(NJPIES)..............1-800-222-1222

WARN DEP..........1-877-927-6337

Important Phone Numbers

Additional Phone Numbers:

Local Health Department

Local Fire Department

Local Police Department

Medical Communication Center

Laboratory Administrator

Emergency Department

Emergency Prep Coordinator

Other

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v Patients in the hospital's EDhave signs and symptoms ofexposure to chemicalterrorism agents.

v Physicians consult withPoison Control (NJ PoisonInformation EducationServices-NJPIES).

v Hospital consults with stateauthorities.

v Determination is made tocollect specimens forchemical terrorism rapid toxicscreen.

v Hospital administrationnotifies the hospital laboratorythat specimens are to becollected and prepared forshipment to New Jersey PublicHealth and EnvironmentalLaboratories.

v Samples need to be collectedQUICKLY to assure agents ormetabolites do not breakdown. Blood needs to becollected ASAP and Urine 7-8hours after exposure toproduce the metabolitestested

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v

v Make arrangements for dry icedelivery (pelletized preferred)

v Dry Ice Vendor Directoryhttp://www.dryicedirectory.com/

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LABELSPrepare specimen labels as you wouldfor routine laboratory specimens toinclude two unique identifiers. v You will need a set of 8 patient

labels for each ADULT specimen: 3-4 for the purple top tubes (depends

on tube size used)

1 for the grey or green top tube

1 for the urine specimen

1 for the urine manifest

1 for the blood manifest

v You will need a set of 2 patient labels for each CHILD specimen:1 for the urine specimen

1 for the urine manifest

DOCUMENTATION

Blood Manifest:https://emergency.cdc.gov/labissues/pdf/chemspecimenshipping-blood1.pdf

Urine Manifest:https://emergency.cdc.gov/labissues/pdf/chemspecimenshipping-urine1.pdf

Hospital Chain of Custody

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v Laboratory should assist the ED incollecting, labeling specimens andcompleting the manifest and the chainof custody forms.

v In addition to unique patient identifiers(e.g. medical records number, specimenidentification number) labels shouldconvey the collectors initials, and dateand time of collection so that lawenforcement officials may trace thespecimen to the collector shouldinvestigations lead to legal action andthe collector has to testify that he/shecollected the specimen.

v If you use bar-coded labels, place thelabels on blood tubes and urine cupsvertically, so that when these containersare upright, the bar code looks like aladder.

v Do not cover expiration date/lot# whenaffixing label to blood tube

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One ADULT SPECIMEN:v ONLY USE TUBES WITHOUT GEL.

v Purple Top Tubes: Collect a minimumof 12 mL of blood by vacuum intofour 3 mL purple top tubes OR three 4mL purple top tubes. DO NOT OPENTHE TUBES. Using indelible ink,number the tubes in order ofcollection (1,2,3,4 or 1,2,3) Initialtubes, date and time. Mix tubes byinversion. Collect ASAP.

v Green or Grey Top Tube: Collect a 3mL or larger green or grey top tube byvacuum. Allow tube to fill to statedcapacity. DO NOT OPEN THE TUBE.Use indelible ink, initial tubes, dateand time. Mix tubes by inversion.

v URINE: Collect 40-60 mL minimum ofurine in clean screwcap urinecontainer. Initial, date and time. Notemethod of collection if urine is notclean-catch. Collect 7-8 hours afterexposure since testing metabolites.

v BLANKS: Two unopened purple toptubes from the same lot#, twounopened grey or green top tube fromthe same lot# and two unopenedurine containers from the same lot#.One blank set is required for each lotutilized.

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TRANSPORT SPECIMENSTO HOSPITAL LABv IMMEDIATELY transport all

specimens from the site ofcollection to the hospitallaboratory for proper temperatureconditioning.

v The sooner specimens reachconditioning temperature, themore likely all analytes will bedetected.

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One CHILD SPECIMEN:v Collect 25 mL minimum of urine in

clean screwcap urine container. Initial,date and time. Note method ofcollection if urine is not clean-catch. Collect 7-8 hours after exposure sincetesting metabolites.

v Two unopened screwcap urinecontainers from the same lot #.

NOTE: Maintain a list of names withcorresponding specimen identificationnumbers at the collection site so thatresults can be reported to patients. It isrecommended that you record additionaldata for use in the interpretation ofresults. Additional data may include;time of potential exposure, method ofurine collection if other than clean-catch, indication if samples werecollected post-mortem and antidotesadministered prior to sample collection.

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TRANSFER BLOODS ANDURINES TO GRIDDED BOXESv Before loading the boxes, remove

the grids and place absorbentmaterial on the bottom. Replace thegrids and place tubes in the box asshown in the pictures on the nextpage.

v Each blood box will hold tubes from10 patients along with blanks. Eachurine box will hold urines from fourpatients and two blanks. Threeurine boxes are needed for everyblood box.

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CONDITION SPECIMENSIN THE LABORATORYBLOOD: DO NOT FREEZE.

Refrigerate blood at 1- 10oCfor a minimum of one hourprior to shipping.

URINE: Freeze urine at -20oC for2 hours or -70oC for 1 hourminimum prior to shipping.

SECURE SPECIMENS WHILECONDITIONING:

Make sure refrigerators andfreezers are locked duringconditioning to maintain chainof custody.

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CONDITION SPECIMENSv Continue to cool the packaged

blood at 1-10oC until ready topackage and ship.

v Freeze urine at -20oC for twohours or -70oC for one hour.

PREPARE MANIFESTS v According to instructions on the

forms.

NOTE: Manifests will accompanyfinal packages. Urine manifestswill accompany urines in dry icebox and blood manifests willaccompany bloods in qualifiedrefrigerated package.

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PREPARE TO PACKAGE:

While specimens are conditioning:

q Secure a driver to Ewing, NJ.

q Obtain dry ice for packaging urine.

q Call NJDOH Chemical Terrorism Laboratory to assure readiness toreceive specimens: 609-508-7417 (Shawn O'Leary).

q Check correct type and amount of specimens collected.

q Check labels are affixed vertically to all containers for easy readof barcodes.

q Check manifests are filled out according to instruction.

q Time the specimen conditioning. After allotted time, visiblycheck to see if urines are frozen.

q Assemble packaging materials – see next page for list ofmaterials needed to package 10 adult specimens.

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Example of Materials for Packaging Chemical TerrorismSpecimens Quantity Listed for Specimens from 10 AdultsES4

Quantity Item Manufacturer Order # Picture

1TCP TimeSaverqualified Shipper or equivalent for 48 hour Refrigeration

TCPor equivalent

FEPS 00351

1Dry Ice Shipper(for Urine)

SafTPakor equivalent

INF 600015 1/2X 14 X 12

1/2

2Freezer Boxes for 6urine samples each

Leigh Laboratoriesor equivalent

BC 3688”X9”X3”

1Test Tube freezerbox Holds 100 – (forblood samples)

Leigh Laboratoriesor equivalent

BC 5100

3Secondary PressureVessel system IATA650 certified (1 for blood2 for urine)TYVEK BAGS


STP 74012”X16”

6 Gridded Box

100 Gridded Box

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4 Quantity Item Manufacturer Order # Picture

3Bitran Polyethylene

Bags WithBiohazard symbols(1 for blood, 2 for

urine)PLASTIC BAGS

VWR 11217-548or equivalent

16 x 16

1Class 9 Hazard

Label(for frozen shipper)

Bureau ofDangerous Goods

DG-94”X4”

1UN 1845 Dry Ice label

(for frozen shipper)


STP 8042”X3”

2BiologicalSubstance,

Category B labels


STP 818 “BiologicalSubstance,Category B”

2UN 3373 Labels Bureau of

Dangerous GoodsDGUN33734”x 4”

2 To: From: labels TO: FROM:

1Evidence Tape

1Filamentous Tape

v Place frozen urine specimensinside gridded box.

v Seal box all the way aroundwith evidence tape, takingcare not to break the tape.Evidence tape should becontinuous and overlapping.

v Write your initials inpermanent marker, half onand half off the evidence tape.

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v Package urine samples first.

Blood should remainrefrigerated as long aspossible before packaging.

v Remove urine samples fromfreezer.

v Check visibly to make surethey are frozen solid.

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PACKAGING FROZEN URINES - #13-29

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v Wrap the urine box inabsorbent paper, and tape withevidence tape as before.

v Write initials in permanentmarker, half on half off theevidence tape.

v Repeat these steps for thesecond gridded urine box.

v (Instructions are for 10 adultspecimens)

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v Place first absorbent-wrappedurine box into polyethelenebag, being sure to displace any air in bag.

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v Place polyethelene bag insideTyvek bag and seal.

v Repeat for second urine box.

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v Seal Tyvek bag with evidencetape and initial half on tapeand half on Tyvek bag.

v Repeat for second urine box.

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v Prepare Saf-T-Pak dry iceshipper. 19

v Place absorbent pad onbottom of dry ice shipper. 20

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v Layer dry ice pellets overabsorbant pad.21

v Place the Tyvek-wrappedurine boxes on top of dry ice.22

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v Brace the Tyvek-wrappedboxes with absorbent pads tominimize shifting.

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v Place pellets of additional dryice on top of absorbentmaterial.

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v Place additional absorbentpad over dry ice.25

v Place urine manifest inside asealable/leak-proof plastic bagand place on top of absorbantpad.

v Do not place Chain of Custodyform in this bag.

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v Place Styrofoam lid overmanifest.

NOTE: Do not tape styrofoamlid shut.

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v Use filamentous tape to sealouter packaging.

NOTE: Do not tape otheredges of the outer packagingto allow for release of carbondioxide gas.

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v Label with the following:

To and From LabelsBiological Substance, Category BUN3373 LabelClass 9 Miscellaneous LabelDry Ice UN1845 with weight in kg

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v Seal the gridded box all theway around with onecontinuous piece of evidencetape (NOTE: evidence tapebreaks apart easily whenapplying to the box).

v Evidence tape should becontinuous and overlapping.

v Initial half on the tape and halfon the top on the box.

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v To maintain temperature ofblood, it will be necessary towork quickly. Recommendedthat packaging be done with asecond person.

v All paperwork should beassembled and completedand packing materials readybefore removing bloodgridded box from refrigerator.

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PACKAGING REFRIGERATED BLOOD - #30-55

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v Place the box sealed withabsorbent inside a Saf-T-Pak clear inner leak-proof polyethylene bag(or equivalent) and seal the bagshut.

NOTE: before sealing thepolyethylene bag, remove the airbuildup from inside the bag.

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v Wrap entire gridded box withabsorbent pad or absorbentsheet and tape to seal.

v Tape with one continuouspiece of evidence tape.

v Evidence tape should becontinuous and overlapping.

v Initial again as shown.

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v Remove excess air from insidethe Tyvek bag and seal theopening of the envelope with acontinuous piece of evidencetape.

v Write initials half on theevidence tape and half on theenvelope.

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v Place the sealed polyethylenebag containing the griddedbox inside the white Tyvekouter envelope. (NOTE: Thesecondary Tyvek bag mustmeet the internal pressurerequirement of 95kpa for airtransport.)

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NOTE: The system is guaranteed to maintainrefrigerated items for 48 hours ONLY IFPACKAGING INSTRUCTIONS ARE FOLLOWED.

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TimeSaver 48 qualified shipping system

Disclaimer: The New Jersey Department of Health does not endorse the sole use of TimeSaver 48. This is provided only asan example. Other equivalent products are available for sale inthe market.

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v TCP shipper withgel packs laid out.37

±

I

t

h

P Repeat this

h

o

(1) EPS Lid

surround Payload Box with (2) refrigerated Gel Packs on each side, and (1) refrigerated Gel Pack on each end

insulated Outer Shipper

(2) layers of 12” x 24” Bubble Wrap folded over

(2) frozen Gel Packs

(2) refrigerated Gel Packs

(2) frozen Gel Packs

(2) layers of 12” x 24” Bubble Wrap folded over

(2) refrigerated Gel Packs

www.cryopak.com ● 888-827-3393

25


v Seal the "payload box" shutwith tape and set aside untilready to be placed inside theTimeSaver 48 prequalifiedshipper.

39

v Place the sealed Tyvek baginside the brown colored“Payload Box” comp onent ofthe TimeSaver 48 prequalifiedshipping system.

v The “Payload Box” is a comp onent of the TimeSaver48 kit and is required by themanufacturer to maintaintemperature for 48 hours.This is not a CDC requirement.

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v Place two (2) frozen gel packshoriz ontally on bottom panel(floor) of the insulated shipper.

NOTE: Freeze the gel packs sothey freeze flat with equalthickness.

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v Empty TimeSaver 48prequalified ship per ready toinitiate "packout" proce durefor shipping the bloodspecimens.

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v Place two (2) refrigerated gelpacks horizontally on top ofthe bubble wrap.

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v Place two (2) layers of bubblewrap on top of the frozen gel packs. NOTE: This is not aCDC requirement.

NOTE: Bubble wrap is included in the packaging.

NOTE: This is not a CDC requirement.

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v Place two (2) refrigerated gelpacks vertically between theright side wall of the shipperbox and the side wall of the payload box, if available. Thisis to help brace the package.Pads can be used as areplacement.

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v Place the payload boxcontaining the bloodspecimens inside the shipperon top of the refrigerated gelpack, cent ered in the cavity.

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v Place one (1) refrigerated gelpack vertically between theend wall of the shipper boxand the end wall of theplayload box.

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v Place two (2) refrigerated gelpacks vertically between theleft side wall of the shipperbox and the right side wall ofthe payload box.

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v Place two (2) refrigerated gelpacks horizontally on top ofthe payload box.

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v Place one (1) refrigerated gelpack vertically between theother end wall of the shipperbox and the end wall of thepayload box.

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v Place two (2) frozen gel packshoriz ontally on top of thebubble wrap.

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v Place two (2) layers ofbubble wrap on top of therefrigerated gel packs.

NOTE: This is not a CDC requirement.

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v Place the lid on the shipper.

NOTE: DO NOT tape the lid shut.53

v Place the completed bloodshipping manifest in asealable plastic bag and placeon top of the frozen gelpacks. DO NOT place Chainof Custody form inside theshipper.

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v Outside box with completedlabeling.55

v Use filamentous tape to sealouter packaging.

NOTE: Do not tape other edgesof the outer packaging to allowfor release of carbon dioxidegas.

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v Driver to sign hospital Chainof Custody (COC) form.

v Driver to sign NJDOH internalCOC form and attain signaturefrom NJDOH on hospital COCform.

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v Final shipment for 10 adultpatient specimens. 56

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Directions to ALTERNATE ENTRANCEFrom I-195 West (OPTION A):Take I-195 West to I-295 North. Follow I-295 South to Exit 75,(Rte. 579 Trenton-Mercer Airport). At the exit ramp bear righttoward West Trenton. At the second light, make a right on UpperFerry Road. Follow Upper Ferry Road about ¾ mile to StatePolice Entrance, on your right. Note: Entrance is shortly after thelarge brick church on the left. Proceed to the guard station andshow ID. At the STOP sign adjacent to the guard station, make aright and proceed up the hill to the second driveway on the left.The large glass building on your left is the PHEAL building.

From I-195 West (OPTION B):Take I-195 West, continue straight at the interchange with I-295,and bear left as the road divides to continue on Route 29. Afterthe Route 29 tunnel by the Riverfront Park baseball stadium,proceed 6 miles north along the Delaware River to the stop lightfor Upper Ferry Road (Route 175) and turn right, following thesign for the State Police Headquarters. Proceed past Villa VictoriaAcademy on your left and stay straight on Upper Ferry Road, notturning left on Route 175/River Rd. (Do not follow the Route. 175sign) for 3/4 mile to the State Police Complex Entrance. PauliesRestaurant will be on your left just before the State PoliceComplex Entrance. Turn left and proceed to the guard station andshow ID. At the STOP sign adjacent to the guard station, make aright and proceed up the hill to the second driveway on the left.The large glass building on your left is the PHEAL building.

From NJ Turnpike (north or southbound):Take turnpike to exit 7A West. Follow signs for I-195 West. FollowOPTION A or OPTION B above.

From the South via Rte 206 North:Take Route 206 North to I-195 West. Follow OPTION A orOPTION B above.

From the West and South via Pennsylvania Turnpike/ I-95 North:Take PA Turnpike East to Exit 28 North. This will put you onRoute 1 North. Follow Route 1 North to Interstate I- 295 East.Take interstate I-295 East and proceed across Scudder’s FallsBridge (toll). Take Exit 76 (Which exits before the bridge ends)and get onto Route 29 South. Make a left turn at the first trafficlight (175 North). Continue less than one mile on Route 175North past Villa Victoria Academy. Stay straight – onto UpperFerry Road. (Route 175 North/River Road bends to the left – donot follow the 175 sign). Turn left at State Police ComplexEntrance. Proceed to the guard station and show ID. At the STOPsign make a right and proceed up the hill, to the seconddriveway on the left. The large glass building on your left is thePHEAL building.

Directions

New Jersey Public Health,Environmental andAgricultural Laboratories(PHEAL)3 Schwarzkopf Dr.,Ewing, NJ 08628Attention: Shawn O'Leary609-508-7417

(Located on the grounds of the New Jersey State Police HeadquartersComplex)

All Employees, Couriers,Vendors and Visitors:USE ALTERNATE ENTRANCE

6:00 AM – 6:00 PM Monday – Friday (non-holidays)

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Directions to MAIN ENTRANCEFrom I-195 West (OPTION A):Take I-195 West to I-295 North. I -295 North becomes I-95 South(one continuous road). Follow I-95 South to Exit 1, (Route 29Trenton/Lambertville). Bear left at the exit onto 29 South(Trenton). Stay in the left lane. Make a left turn at the first trafficlight (175 North). Stay on Route 175 North past Villa VictoriaAcademy and the bend in the road. State Police Headquartersmain entrance is about 1/2 mile further on your right. Continueto the guard station. Show ID and ask the guard to direct you tothe laboratory building – large glass building on opposite side ofcampus.

From I-195 West (OPTION B):Take I-195 west, continue straight at the interchange with I-295,and bear left as the road divides to continue on Route 29. Afterthe Route 29 tunnel by the Riverfront Park baseball stadium,proceed 6 miles north along the Delaware River to the stop lightfor Upper Ferry Road (Route 175) and turn right, following thesign for the State Police Headquarters. Proceed past Villa VictoriaAcademy for 1/2 mile and turn left to stay on Route 175/RiverRoad. State Police Headquarters Main Entrance is about 1/2 mileafter the left turn on your right. Continue to the guard station.Show ID and ask the guard to direct you to the PHEAL laboratorybuilding – large glass building on opposite side of campus.

From NJ Turnpike (north or southbound):Take turnpike to exit 7A West. Follow signs for I-195 West. FollowOPTION A or OPTION B above.

From the South via 206 North:Take 206 North to I-195 West. Follow OPTION A or OPTION Babove.

From the West via Pennsylvania Turnpike/ I-95 North:Take PA Turnpike East to Exit 28 North. This will put you onRoute 1 North. Follow Route 1 North to Interstate I-95 North.Take interstate I-95 North and proceed across Scudder’s FallsBridge. Take Exit 1 (Which exits before the bridge ends. Stay inthe left lane. Make a left turn at the first traffic light (175 North).Continue on Route 175 North past Villa Victoria Academy andthe left bend. State Police Headquarters main entrance is about1/2 mile further on your right. Continue to the guard station.Show ID and ask the guard to direct you to the laboratorybuilding – large glass building on opposite side of campus.

Directions

All Employees, Couriers,Vendors and Visitors:USE MAIN ENTRANCE

6:00PM – 6:00AM (non-holidays), any time duringholidays and weekends

COURIERS WITH ANY DELIVERY:

8:30 AM – 4:00 PM Monday – Friday (non-holidays) 1-609-530-8387

Follow the signs to the LoadingDock/Specimen Receiving areabehind the PHEAL building.

All other times (prior arrangementsmust be made for emergency/afterhours analysis)

Park in the front lot, go to the mainentrance and check in with thesecurity guard at the desk.

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CDC References:1. Flowchart: Chemical Terrorism Event Specimen Collection

http://emergency.cdc.gov/labissues/pdf/Flowchart_CT_Event_Specimen_collection_modified_08/2016.pdf

2. Chemical Agents: Shipping Instructions for SpecimensCollected From People Who May Have Been Exposed toChemical-Terrorism Agents - Updated May 2013http://emergency.cdc.gov/labissues/specimens_shipping_instructions.asp

3. Chemical Agents: Chemical Terrorism Blood SpecimenCollection and Shipping Manifesthttp://emergency.cdc.gov/labissues/pdf/chemshippingform-blood.pdf

4. Chemical Agents: Chemical Terrorism Urine SpecimenCollection and Shipping Manifesthttp://emergency.cdc.gov/labissues/pdf/chemshippingform-urine.pdf

5. CDC's Lab Response to Suspicious Substanceshttp://emergency.cdc.gov/labissues/substanceresponse.aspExplains how federal, state, and local agencies respond tothreatening letters and how labs play a role in detection andresponse.

6. CDC Laboratory Response Network (LRN) websitehttp://emergency.cdc.gov/lrn/Overview of the LRN, an integrated network of state & localpublic health, federal, military, and international labs that canrespond to both bioterrorism and chemical terrorism.

USDOT Reference:Packaging Instructions for Infectious Substances, Category B 49 CFR 173.199

TCP Manufacturer's Instructions:TimeSaver 48 Hour 2-8oC Pre-qualified shippers - Blood Specimens

References

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C2661

Chemical Terrorism Packaging and Shipping Just...check to see if urines are frozen. q Assemble packaging materials – see next page for list of materials needed to package 10 adult

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