Form Cdph 4453 – Fill Out and Use This PDF

State of California––Health and Human Services Agency	California Department ofPublic Health
	Genetic Disease Screening Program
	California PrenatalScreening Program

REQUEST FOR CALIFORNIA PRENATAL SCREENING PROGRAM SUPPLIES

FOR CLINICIANS ONLY

Mailing address:	To Order Supplies:
California Department of Public Health	Toll-free phone: (877) 984	-8450
Prenatal Screening Program Supplies	Toll-free fax: (877) 984	-8650
850 Marina Bay Parkway, F175	email: CernX.sac@cernx.com

Richmond, CA 94804-6403

Organization/department	Telephone number		Fax number
	(	)	(	)
Address (number, street, suite number)	City		State		ZIP code

•Please use Blood Shipping Kits for blood specimens sent via U.S. mail or GSO. Order “tubes only” if using other courier service.

•Please use one tray, one pouch, and one box to send one or two specimens if they are drawn the same day.

	Item Description	Quantity Request ed
		(Enough for 6-Month Supply)
First Trimester Prenatal Screening Forms (blue edge)
Second Trimester Prenatal Screening Forms (green edge)
Blood Shipping Kit	(Kits contain one 3.5ml serum separator tube (SST), one tray, one pouch, and
	one box to mail the blood specimen in.)
For individual items, CIRCLE as needed : TUBES / TRAYS / POUCHES / BOXES

Indicate (below) the number of booklets/pamphlets needed in each language:

Prenatal Diagnosis of Birth Defects	English	Spanish	Chinese	Vietnamese	K orean
Patient Booklet (includes Consent F orm)

“Easy-to-Read” Pamphlet (as of June 2009 )		*	*	*
Prenatal Diagnosis of Birth Defects		*	*	*
Folate pamphlet
“Before and During Pregnancy, You Need Folate”
Prenatal Screening Program
Provider Handbook (One per clinician)
Important Information About the Newborn
Screening Test (English & Spanish combined)

Screen Positive Brochures (Distributed to Prenatal Diagnosis Centers for women with screen positive results):

	Down Syndrome		First Trimester						* Screen PositiveBooklets in Chinese, Korean,
									and Vietnameseas well asother Program
			Second Trimester
									materials may be found on the Program website
			First Trimester						at:
	Trisomy 18								www.cdph.ca.gov/programs/pns
			Second Trimester
									How many NEW OB
	Neural Tube Defects or Abdominal Wall Defects
									patients per month :
	Smith-Lemli -Opitz Syndrome
	Large Nuchal Translucency
	PREGNANCY CALCULATION WHEEL

All Prenatal Screening supplies are the property of the State of California. Other use is strictly prohibited.

Allow 2-4 Weeks for Delivery

For Questions and Concerns: CALL (510) 412-1441

CDPH 4453 (1/13)

State of California –– Health and Human Services Agency	California Department of Public Health
	Genetic DiseaseScreening Program
	California Prenatal Screening Program

REQUEST FOR CALIFORNIA PRENATAL SCREENING PROGRAM SUPPLIES

FOR LABORATORIES AND DRAW STATIONS ONLY

(Clinicians Use Other Side)

Mailing address:	To Order Supplies:
California Department of Public Health	Toll-free phone: (877) 984	-8450
Prenatal Screening Program Supplies	Toll-free fax: (877) 984	-8650
850 Marina Bay Parkway, F175	email: CernX.sac@cernx.com
Richmond, CA 94804 -6403

Name of laboratory/draw station

Organization/department	Telephone number		Fax number
	(	)	(	)
Address (number, street, suite number)	City		State		ZIP code

•Please use Blood Shipping Kits for blood specimens sent via U.S. mail or GSO Order “tubes only” if using other courier. service

•Please use one tray, one pouch, and one box to send one or two specimens if they are drawn the same day.

	Item Description	Quantity Requested
		(Enough for 6-Month Supply)
Blood Shipping Kit	(Kits contain one 3.5ml serum separator tube (SST), one tray, one pouch, and
	one box to mail the blood specimen in.)

For individual items, CIRCLE as needed: TUBES / TRAYS / POUCHES / BOXES

Please note:

1.Prenatal Care Provider will complete Part A of the Prenatal Screening Test Request Form.

2.Phlebotomist at laboratory/draw station must complete Part B of the Prenatal Screening Test Request Form.

3.Please photocopy this supply form for future requests.

The California Prenatal Screening Program bills patients directly for the Program fee. Laboratories may bill patients separately a reasonable fee for drawing and handling blood specimens, taking into account that the State Program provides tubes and mailing supplies free of charge to laboratories and draw stations, as well as clinicians.

Reminder: Use only Beckton- Dickinson 3.5ml Serum Separator Tubes (SST) with a gold “vacutainer” top as supplied by the Prenatal Screening Program. Screening test results are based upon calibration for these tubes only .

Important Note: First Trimester specimens MUST be centrifuged or they cannot be analyzed .

Program information and materials may be found on the Program website at:

www.cdph.ca.gov/programs/pns

All Prenatal Screening supplies are the property of the State of California. Other use is strictly prohibited. Allow 2 -4 Weeks for Delivery

For Questions and Concerns: CALL (510) 412-1441

CDPH 4453 (1/13)