NSQPA Pilot SMA PT Data Reporting Form

				Form Approved
				OMB No. 0920-0879
				Exp. Date 01/31/2021
	Newborn Screening Quality Assurance Program
	Survival Motor Neuron 1 (SMN1) Exon 7 Analysis in Dried-Blood Spots
	To Detect Spinal Muscular Atrophy (SMA) Pilot Proficiency Testing Program (Pilot SMAPT)
	Note: Any data submission form which is NOT current OR has been altered will NOT be accepted
	Proficiency Testing: Pilot PT Program		Issued: June 15, 2020 Data Reporting Deadline: July 10, 2020	Email your complete worksheet to Irene Williams at NSQAPDMT@cdc.gov The phone number is 770-488-7024
	NSQAP Laboratory Code:
	Select Method Code from drop-down menu: LDT refers to Lab Developed Test RUO refers to Research Use Only
	If Other selected, YOU MUST list commercial method or describe lab developed test:
	Select DNA Extraction Method from drop-down menu:
	If Other selected, YOU MUST describe:
	SMN1 assay primer and probe information*
	SMN1 probe sequence including dye and quencher:
	SMN1 forward amplficiation primer sequence:
	SMN1 reverse amplficiation primer sequence:
	Reference Gene assay primer and probe information*
	Select Reference Gene from drop-down menu:
	If Other selected, YOU MUST specify gene name and symbol:
	Reference gene probe sequence including dye and quencher:
	Reference gene forward amplficiation primer sequence:
	Reference gene reverse amplficiation primer sequence:
	*Input "not available" in the Other secion of each probe category if using a commercially available assays for which this information is not available.
	Specimen Number	Analyte	Clinical Assessment Code (Select from Drop-down Menu)	Comment
	20P1701	SMN1 Exon 7
	20P1702	SMN1 Exon 7
	20P1703	SMN1 Exon 7
	20P1704	SMN1 Exon 7
	20P1705	SMN1 Exon 7
	Participating laboratories must generate and submit their own results and must not share NSQAP Pilot PT test results or specimens with any other laboratory under ANY circumstance, even if the laboratory normally sends specimens to referral laboratories for routine or confirmatory testing. If participants are found to have falsified or shared results or specimens, the NSQAP committee will convene to discuss response actions for the participant which may include termination from the program.
	Use of trade names is for identification only and does not imply endorsement by the Public Health Service, the U.S. Department of Health and Human Services, or the Association of Public Health Laboratories.