Form 8 Administrative form for the Pathologist

A multi-center international hospital-based case-control study of lymphoma in Asia (AsiaLymph) (NCI)

Attach 8 -_Admin_form_pathologist_REV_07-02-12

Pathologist Administrative Form (Attachment 8)

OMB: 0925-0654

Document [pdf]
Download: pdf | pdf
For pathologist component of reporting form:
OMB #: 0925-0654
Expiration date: 09/30/2012
Public reporting for this collection of information is estimated to average 5 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and
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completed form to this address.

1

AsiaLymph Study
Pathology Specimen Request & Tracking

Subject ID
(Affix label here)

Section 1: Prepared by Interviewer
Hospital AsiaLymph ID:

Hospital Name:____________________________

/

Date Requested:

D
D
Study Subject Patient’s Name

M

M

/

Y

Y

Patient’s Hong Kong ID Number

YES
NO

Is patient from a referral hospital?

Y
Y
Patient’s Hospital / Outpatient Clinic Number

Referral hospital name: _______________________________________________
Interviewer name: ______________________________________________
Name

Section 2: Prepared by Pathologist or Delegate
Date slides cut:
D

D

/

M

M

/

Pathology specimen number:
Y

Y

Y

Y

Pathologist: __________________________________________________
Name

Unstained Slides

Thick Sections (20 µ)

Section Sequence

Section Created

0341

Number of slides cut: ________

0342
If no unstained slides are cut, please provide original diagnostic slides which will be returned after review
Enter number of stained slides: ________

Enter number of immunostained slides: ________

Diagnostic slides were made at:

Referral Hospital

Study Hospital

If original diagnostic slides are not provided, are they available for future review?
Diagnostic slides available at:
Is frozen tissue is available?

Referral Hospital

YES

YES

NO

Study Hospital

NO

Section 3: Prepared by Interviewer
Date slides picked up from pathology lab:
D

D

/

M

M

/

Y

Y

Y

Date slides mailed to Pathology Center (QEH):
Y

D

D

/

M

M

/

Y

Y

Y

Y


File Typeapplication/pdf
AuthorCharlie Lawrence
File Modified2012-07-02
File Created2012-02-26

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