Web:	MayoMedicalLaboratories.com
Email:	mml@mayo.edu
Telephone:	800.533.1710
International:	507.266.5700
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NT/CRL Data Form

Thank you for choosing Mayo Medical Laboratories.

All sonographers within the organization must complete this form separately.

Prior to submitting this form, be sure that you have completed the required items on the First Trimester Maternal Screen information page.

As a reminder, we will only accept nuchal translucency (NT) measurements from certified sonographers.

All Fields Are Required

Primary Client Information
If the sonographer is completing this form, contact your laboratory for the following information. All fields are required.
Account Name
Mayo Medical Laboratories Account Number (C#)
Contact
Address
Address
Phone Number
Sonographer QC data will be provided on a regular basis. Please select one of the following:
Client agrees to distribute QC data to the sonographer.
Client Email
Please send QC data directly to the sonographer

Sonographer Information
Complete the following for each sonographer performing NTs for First Trimester Screening.
Sonographer Last Name
Sonographer First Name
Certifying Agency
	NTQR/DMSTAT DMSTAT Site ID
	FMF
	FASTER
Certification Number
Sonographer Phone
Sonographer Email
Expected Number of NTs/Month for First Trimester Screening
Sonographer's Supervisor
Supervisor's Phone Number
Supervisor's Email
Does the Sonographer Provide NT Services for Other Institutions?	Yes No
Where?

Sonographer Data
Please supply the matched NT/CRL measurements. Sonographers should provide paired NT/CRL measurements from as many pregnancies as possible to validate the appropriate reference data.

How would you like to submit this data?
Attach a spreadsheet.

Enter data manually.