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6 mm or greater than 84. 5 mm the NT exam data cannot be used for risk assessment. If CRL is greater than 84. 5 mm convert the CRL or BPD to gestational age and include this on the ultrasound report that you are providing the clinician. CRL and NT must be reported in millimeters. Please round to one decimal place. Please write clearly. If you have already entered NT data into SIS it is not necessary to send this form to the clinician or to the Coordinator. FORM COMPLETED BY NAME Last First TELEPHONE NUMBER PATIENT INFORMATION DATE OF BIRTH TEST REQUEST FORM If Available NAME OF PRENATAL CARE PROVIDER NT PRACTITIONER CRED NT SITE CODE Optional NT SUPERVISOR CRED Optional. NT EXAM DATE - NT FETUS A CHECK IF UNABLE TO MEASURE CRL CRL FETUS A mm TWIN PREGNANCY YES NO IF TWINS WHAT IS THE CHORIONICITY NT MONOCHORIONIC DICHORIONIC UNABLE TO DETERMINE REQUIRED FIELDS o If the CRL is less than 44. 6 mm or greater than 84. 5 mm the NT exam data cannot be used for risk assessment. If CRL is greater than 84. State of California - Health and Human Services Agency California Department of Public Health Genetic Disease Screening Program Telephone 510/412-1502 NUCHAL TRANSLUCENCY EXAM DATA CALIFORNIA PRENATAL SCREENING PROGRAM CLINICIANS Please write this information on the 1st or 2nd trimester lab form for submittal to the California Prenatal Screening Program with the blood specimen. If you have already submitted the 1st trimester blood specimen but want 1st trimester risk assessment please call the case coordinator. FORM COMPLETED BY NAME Last First TELEPHONE NUMBER PATIENT INFORMATION DATE OF BIRTH TEST REQUEST FORM If Available NAME OF PRENATAL CARE PROVIDER NT PRACTITIONER CRED NT SITE CODE Optional NT SUPERVISOR CRED Optional. State of California - Health and Human Services Agency California Department of Public Health Genetic Disease Screening Program Telephone 510/412-1502 NUCHAL TRANSLUCENCY EXAM DATA CALIFORNIA PRENATAL SCREENING PROGRAM CLINICIANS Please write this information on the 1st or 2nd trimester lab form for submittal to the California Prenatal Screening Program with the blood specimen* If you have already submitted the 1st trimester blood specimen but want 1st trimester risk assessment please call the case coordinator. FORM COMPLETED BY NAME Last First TELEPHONE NUMBER PATIENT INFORMATION DATE OF BIRTH TEST REQUEST FORM If Available NAME OF PRENATAL CARE PROVIDER NT PRACTITIONER CRED NT SITE CODE Optional NT SUPERVISOR CRED Optional. NT EXAM DATE - NT FETUS A CHECK IF UNABLE TO MEASURE CRL CRL FETUS A mm TWIN PREGNANCY YES NO IF TWINS WHAT IS THE CHORIONICITY NT MONOCHORIONIC DICHORIONIC UNABLE TO DETERMINE REQUIRED FIELDS o If the CRL is less than 44. 6 mm or greater than 84. 5 mm the NT exam data cannot be used for risk assessment. If CRL is greater than 84. 5 mm convert the CRL or BPD to gestational age and include this on the ultrasound report that you are providing the clinician* CRL and NT must be reported in millimeters. Please round to one decimal place. Please write clearly. If you have already entered NT data into SIS it is not necessary to send this form to the clinician or to the Coordinator.