Cytogenetics Laboratory: Laboratory Information, Clinical Case Reports, and Proficiency Testing Participation

Transcription

1 Cytogenetics Laboratory: Laboratory Information, Clinical Case Reports, and Proficiency Testing Participation Complete one form for each cytogenetics laboratory associated with the training program. List clinical caseload in each category below for the last twelve-month period. Do not include research or test development data. NOTE: If the laboratory is offsite, a signed Laboratory/Clinic Training Arrangement Form must be submitted. Name and Address of Laboratory: Name of Laboratory Director(s): Period Covered [from MM/DD/YYYY through MM/DD/YYYY]: Licensure - List all license numbers AND expiration dates: CLIA: State: Other: Accreditation Inspection(s): Most recent onsite CAP inspection date : Most recent onsite CLIA inspection date: Other inspection (please specify): ; most recent onsite inspection date: Category BLOOD TISSUE SKIN / POC AMNIOTIC FLUIDS CHORONIC VILLI NEOPLASTIC BLOOD / MARROW Number of Cases TUMORS OTHER (specify)

2 Cytogenetics, continued List all proficiency testing programs in which this cytogenetics laboratory participates. Add rows as needed. Do not send documentation. Organization (e.g., CAP, Other) PROFICIENCY TESTING PT Test Name

3 Biochemical Genetics Laboratory: Laboratory Information, Clinical Case Reports, and Proficiency Testing Participation Complete one form for each biochemical genetics laboratory associated with the training program. List clinical caseload in each category below for the last twelve-month period. Do not include research or test development data. NOTE: If the laboratory is offsite, a signed Laboratory/Clinic Training Arrangement Form must be submitted. Name and Address of Laboratory: Name of Laboratory Director(s): Period Covered [from MM/DD/YYYY through MM/DD/YYYY]: Licensure - List all license numbers AND expiration dates: CLIA: State: Other: Accreditation Inspection(s): Most recent onsite CAP inspection date : Most recent onsite CLIA inspection date: Other inspection (please specify): ; most recent onsite inspection date: Category Methodology(ies)* Number of Cases Newborn Screening for State or Private Sector MS/MS Acylcarnitine Profile Tandem Mass Spectrometry Analysis (Non-Newborn Screening) specify test(s) MS/MS MS/MS Plasma/Urine/CSF Amino Acid Determinations Organic Acid Determinations Prenatal Diagnoses (List disorder and enzyme of analyte) Enzyme Testing (List Disorder / Enzyme) Other Areas of Evaluation (please specify each): * Methodology: Identify method used, e.g., GC/MS, HPLC, immunoassay, ELISA, etc.

4 Biochemical Genetics, continued List all proficiency testing programs in which this biochemical genetics laboratory participates. Add rows as needed. Do not send documentation. Organization (e.g., CAP, Other) PROFICIENCY TESTING PT Test Name

5 Molecular Genetics Laboratory: Laboratory Information, Clinical Case Reports, and Proficiency Testing Participation Complete one form for each molecular genetics laboratory associated with the training program. List the clinical caseload in each category below for the last twelve-month period. Do not include research or test development data. NOTE: If the laboratory is offsite, a signed Laboratory/Clinic Training Arrangement Form must be submitted. Name and Address of Laboratory: Name of Laboratory Director(s): Period Covered [from MM/DD/YYYY through MM/DD/YYYY]: Licensure: List all license numbers AND expiration dates: CLIA: State: Other: Accreditation Inspection(s): Most recent onsite CAP inspection date : Most recent onsite CLIA inspection date: Other inspection (please specify): ; most recent onsite inspection date: Total Number of Name of Disease Indication for Testing* Diagnostic Method(s)** Tests Performed * Indication for Testing: diagnostic, predictive, carrier determination, carrier screening, other, unknown. ** Diagnostic Method(s): RFLP/gel, sequencing, array, allele specific platform, Real Time PCR, etc.

6 Molecular Genetics, continued List all proficiency testing programs in which this molecular genetics laboratory participates. Add rows as needed. Do not send documentation. PROFICIENCY TESTING Organization (e.g., CAP, Other) PT Test Name