California Prenatal Screening Program
Nuchal Translucency Exam Data and Time Windows for Blood Draws

NT Practitioner Instructions:
  • Enter the data from the NT exam and click the “Calculate Blood Draw Dates” button.
  • Print form and fax to the referring Clinician with a cover sheet.
  • This screen is not connected to SIS, the Program's computer. If the NT Exam data is being entered in SIS, check the following box:
  •  This NT Exam data is being entered separately into the Program’s computer.

Clinician Instructions:

  • Submit this NT Exam data to the Prenatal Screening Program on a Test Request Form (TRF) with a blood draw.
  • The dates provided here are when blood specimens for prenatal screening should be drawn.
        Today's Date:  
Patient Information       (Fields with * are required)
Last Name* First Name* Test Request Form # Date of Birth*
Pick a date  
Nuchal Translucency Information
NT Practitioner CRED#* NT Supervisor CRED# CRL (FETUS A)* Check if unable to measure CRL Twin Pregnancy?* CRL (FETUS B)* Check if unable to measure CRL
   mm   Yes No mm
NT Site Code NT Exam Date* NT (FETUS A)* Check if unable to measure NT If Twins, What is the Chorionicity? NT (FETUS B)* Check if unable to measure NT
  Pick a date mm   Monochronic mm
      Dichorionic

 

        Unable to Determine    
Form Completed BY  
Last Name First Name

Telephone

   

Gestational Age at Time of Exam :
Gestational Age Today :
  
First Trimester Blood Specimen Time Window 10 Weeks 0 Days 13 Weeks 6 Days     
First trimester blood specimen should be drawn between: and
Second Trimester Blood Specimen Time Window 15 Weeks 0 Days 20 Weeks 0 Days
Second trimester blood specimen should be drawn between: and

Comments: