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pdfOMB #: 0925-0654
Expiration date: 10/31/2015
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 maintaining
the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA
(0925-0654). Do not return the completed form to this address.
Case Tracking Form
Study Subject ID
Label
Patient (Study Subject)
Hospital ID Number
=Y =Y
=Y =Y
=Y
=NA =NA =Y =NA =NA =Y =NA
dd/mm/yy
yy
=Y =Y
[
/
/
C
C
o
Write in each test scanned
Pathology Reports
Scanned
Discharge Summary
Scanned
=Y
=NA
CT, MRI, Admission CBC & Standard
Tests*
Enroll
ment
Date
of
Contr
ol for
this
Case
=Y dd/m
=NA m/yyy
Subject ID Number of Control
that is Matched to Case
(write in ID Number)
]
o
o
o
o
o
o
o
AS _ _ _ _ _
o
o
o
o
o
o
o
AS _ _ _ _ _
o
o
o
o
o
o
o
AS _ _ _ _ _
o
o
o
o
o
o
o
AS _ _ _ _ _
o
[
R
R
/
/
C
C
o
]
o
[
[
R
R
/
/
C
C
]
o
]
o
[
[
R
R
/
/
C
C
]
]
o
R
]
o
o
R
[
o
o
o
]
o
o
o
[
o
Buccal Cell Collection &
Delivery
Blood Collection &
Delivery
Pathology Tissue
Requested
Pathology Slides & Vials
Received
Pathology Slides & Vials
Transferred to SC
Consent &Comp Forms
Scanned
Date
Informed
Consent
Obtained
Admission Report
Scanned
Hospital Name: ___________________________
_____________________
Comp
Paid
Patient
(Study
Subject)
Name
(Last, First)
ccc
CAPI Complete
Interviewer Initials (ID) and Name
*CT, MRI, Admission CBC & Standard Tests (e.g., liver function, renal function) viral tests for hepatitis and MRI, flow cytometry, bone marrow studies, nuclear scans, etc. IF ANY OF LISTED TEST ABOVE IS UNAVAILABEL, for instance, MRI
test, please write in "No MRI test found". **=Yes, =NA(not available), =N(No); o=Nothing has been done. [R/C]=if NA was checked, please circle =Patient Refused or =Could not collect
Page _____
OMB #: 0925-0654
Expiration date: 10/31/2015
Public reporting for this collection of information is estimated to average 15 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA
(0925-0654). Do not return the completed form to this address.
Control Selection Record
Control Selection Record
1. Characteristics of Case Requiring a Matching Control:
Control Matching Criteria:
Case Subject ID:
a) Gender:
b) Date of Birth/Age:
c) Hospital:
d) Enrollment Date:
AS-c
e) Area of Residence:
f) Resident of Core Geographic
_______________________
Yes No
Region for at least 15 years?
cccc
M F
_____________________
_____________________
_____________________
(dd/mm/yyyy):
Same gender
Within +/- 5 years of age
From the same hospital as the case
Within +3 months of case enrollment
2. Approach used to select a potential control for the case identified above.
a) Specify control disease category selected to identify potential controls (check one):
Injuries
Diseases of the circulatory system
Diseases of the digestive system
b) Specify admission lists reviewed to identify potential controls:
Diseases of the genitourinary system
Diseases of the central nervous system and sense organs
c) How many potential controls were identified who match the characteristics of the case identified above:
N= _______
d) Fill in table using data on these potential controls from medical records
Date and time
Identified
Name
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
Age
Sex
Disease
Geographic Region of
Current Residence
(dd/mm/yyyy);
(am or pm)
DO NOT PRE-LABEL
Subject ID
(Affix label here)
Control Subject ID
cONT
e)
Describe how a specific potential control subject was randomly selected to approach for enrollment
f)
Names and outcome of first (and if needed, because of being ineligible or refusal) subsequent potential control subject selected to
approach as the matched control for case indentified above:
Name
Date and Time Approached
(dd/mm/yyyy; hour:min)
Enrolled?:
Yes/No
1)
2)
3)
g)
Additional control eligibility criteria to be determined based on responses to screening questions:
h)
No history of lymphoma.
Having lived within the study center’s core geographic region at some time for at least 15 years.
Following enrollment, paste selected control’s Subject ID label in the upper right corner above, and on front page of form.
OMB #: 0925-0654
Expiration date: 10/31/2015
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 maintaining
the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA
(0925-0654). Do not return the completed form to this address.
Control Tracking Form
[
]
o
o
[
R
/
C
R
/
C
]
o
o
[
[
R
/
C
R
/
C
]
]
o
o
[
[
R
/
C
R
/
C
]
]
o
R
/
C
]
o
o
R
/
C
[
o
o
o
]
o
o
o
[
o
=Y
=NA
=Y
=NA
=Y
=NA
o
o
o
AS _ _ _ _ _
o
o
o
AS _ _ _ _ _
o
o
o
AS _ _ _ _ _
o
o
o
AS _ _ _ _ _
Discharge
Summary
Scanned
=Y
Admission Report
Scanned
Patient
(Study
Subject)
=Y
Hospital ID dd/mm/yy
=NA
yy
=Y
=Y
Number
Subject ID
Number of
Case that
Name of Control is
Case that Matched to
CT, MRI, Admission CBC & Standard Tests* Control is
Matched Write in ID
Write in each test scanned
Number
to
Consent & Comp
Forms Scanned
Buccal Cell
Collection &
Delivery
Blood Collection
& Delivery
Date
Informed
Consent
Obtained
Study Subject ID label
Hospital Name: ___________________________
_____________________
Comp
Paid
Patient
(Study
Subject)
Name
(Last, First)
ccc
CAPI Complete
Interviewer Initials (ID) and Name
*CT, MRI, Admission CBC & Standard Tests (e.g., liver function, renal function) viral tests for hepatitis and MRI, flow cytometry, bone marrow studies, nuclear scans, etc. IF ANY OF LISTED
TEST ABOVE IS UNAVAILABEL, for instance, MRI test, please write in "No MRI test found". **=Yes, =Not available, o=Nothing has been done. [R/C]=if NA was checked, please circle
=Patient Refused or =Could not collect.
Page _____
OMB #: 0925-0654
Expiration date: 10/31/2015
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 maintaining
the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA
(0925-0654). Do not return the completed form to this address.
Blood Collection and Processing Form
AsiaLymph Study
Blood Collection and Processing
Page 1
Subject ID
(Affix label here)
Select hospital where specimen was collected
Hong
Hong Kong
Kong Study
Study Center
Center (#1)
(#1)
c
c
c
c
c
c
c
c
c
c
Tianjin
Tianjin Study
Study Center
Center (#3)
(#3)
Queen
Queen Mary
Mary Hospital
Hospital
Queen
Queen Elizabeth
Elizabeth Hospital
Hospital
Tuen
Tuen Mun
Mun Hospital
Hospital
Princess
Princess Margaret
Margaret Hospital
Hospital
Pamela
Pamela Youde
Youde Eastern
Eastern Hospital
Hospital
c
c
c
c
c
c
c
c
c
c
Tianjin
Tianjin Medical
Medical University
University Cancer
Cancer Institute
Institute and
and Hospital
Hospital
Tianjin
Tianjin Medical
Medical University
University General
General Hospital
Hospital
Tianjin
Tianjin First
First Center
Center Hospital
Hospital
Second
Second Hospital
Hospital of
of Tianjin
Tianjin Medical
Medical University
University
Institute
Institute of
of Hematology
Hematology &
& Blood
Blood Diseases
Diseases Hospital
Hospital
Chengdu
Chengdu Study
Study Center
Center (#2
(#2))
Taiwan
Taiwan Study
Study Center
Center (#4)
(#4)
c
c Sichuan
Sichuan University
University Hua
Hua Xi
Xi Hospital
Hospital
c
c
c
c
c
c
c
c
c
c
c
c
c
c
(West
(West China
China Hospital)
Hospital)
c
c Sichuan
Sichuan Province
Province People’s
People’s Hospital
Hospital
c
c Sichuan
Sichuan Tumor
Tumor Hospital
Hospital
Dalin
Dalin Tzu
Tzu Chi
Chi General
General Hospital
Hospital
China
China Medical
Medical University
University Hospital
Hospital
Kaohsiung
Kaohsiung Chang
Chang Gung
Gung Memorial
Memorial Hospital
Hospital
Chia-Yi
Chia-Yi Christian
Christian Hospital
Hospital
Kaohsuing
Kaohsuing Medical
Medical University
University Hospital
Hospital
National
National Cheng
Cheng Kung
Kung University
University Hospital
Hospital
Chi-mei
Chi-mei Medical
Medical Center
Center Hospital
Hospital
Subject Information (to be completed by Interviewer)
Control
Case
Blood Prescreening Questions (phlebotomist to ask patient prior to blood draw)
_____ HOURS AGO
1) When was the last time you had anything to eat or drink besides water or tea?
2) When was the last time you smoked? _____ HOURS AGO, or CHECK IF NON SMOKER
3) Have you had any problems with a blood draw in the past?
YES
NO
DON’T KNOW
Blood Collection Information (to be completed by phlebotomist)
Date and time of blood draw:
DATE: ____ / ____ / ____ TIME: ____ : ____
Blood collected by (NAME and English Initials): ______________________________________
Tube 0021
Collection Status
Collected
Tube 0022
Collection Status
Collected
Tube 0023
Not collected
Not collected
Collection Status
Collected
Not collected
Date blood specimens or aliquots received at Study Center
(to be completed by Study Center)
D
Received by: ______________________________________________
Name
D
/
M
M
/
Y
Y
Y
Y
AsiaLymph Study
Blood Collection and Processing
Page 2
Subject ID
(Affix label here)
(complete if computer/Internet access is not available)
Blood Tube Receipt
Enter Date Received at lab: ____ / ____ / ____
Enter Time Received: ____ : ____
Specimen receipted by(NAME and English Initials): ____________________________
Tube 0021 Receipt Condition
Received OK
Not received
Tube 0022 Receipt Condition
Received OK
Not received
Tube 0023 Receipt Condition
Received OK
Not received
Blood Processing
Time Aliquoted: ____ : ____
Plasma Aliquots
Sequence
Created
Sequence
Created
Sequence
0211
0214
0217
0212
0215
0218
0213
0216
0219
Created
BC/RBC Aliquots
Sequence
0231
0234
Created
Sequence
0232
Created
Sequence
0233
Created
OMB #: 0925-0654
Expiration date: 10/31/2015
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 maintaining
the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA
(0925-0654). Do not return the completed form to this address.
Buccal Cell Collection and Processing Form
AsiaLymph Study
Buccal Cell Collection and Processing
Subject ID
(Affix label here)
Select hospital where specimen was collected
Hong
Hong Kong
Kong Study
Study Center
Center (#1)
(#1)
c
c
c
c
c
c
c
c
c
c
Tianjin
Tianjin Study
Study Center
Center (#3)
(#3)
Queen
Queen Mary
Mary Hospital
Hospital
Queen
Queen Elizabeth
Elizabeth Hospital
Hospital
Tuen
Tuen Mun
Mun Hospital
Hospital
Princess
Princess Margaret
Margaret Hospital
Hospital
Pamela
Pamela Youde
Youde Eastern
Eastern Hospital
Hospital
c
c
c
c
c
c
c
c
c
c
Tianjin
Tianjin Medical
Medical University
University Cancer
Cancer Institute
Institute and
and Hospital
Hospital
Tianjin
Tianjin Medical
Medical University
University General
General Hospital
Hospital
Tianjin
Tianjin First
First Center
Center Hospital
Hospital
Second
Second Hospital
Hospital of
of Tianjin
Tianjin Medical
Medical University
University
Institute
Institute of
of Hematology
Hematology &
& Blood
Blood Diseases
Diseases Hospital
Hospital
Chengdu
Chengdu Study
Study Center
Center (#2
(#2))
Taiwan
Taiwan Study
Study Center
Center (#4)
(#4)
c
c Sichuan
Sichuan University
University Hua
Hua Xi
Xi Hospital
Hospital
c
c
c
c
c
c
c
c
c
c
c
c
c
c
(West
(West China
China Hospital)
Hospital)
c
c Sichuan
Sichuan Province
Province People’s
People’s Hospital
Hospital
c
c Sichuan
Sichuan Tumor
Tumor Hospital
Hospital
Dalin
Dalin Tzu
Tzu Chi
Chi General
General Hospital
Hospital
China
China Medical
Medical University
University Hospital
Hospital
Kaohsiung
Kaohsiung Chang
Chang Gung
Gung Memorial
Memorial Hospital
Hospital
Chia-Yi
Chia-Yi Christian
Christian Hospital
Hospital
Kaohsuing
Kaohsuing Medical
Medical University
University Hospital
Hospital
National
National Cheng
Cheng Kung
Kung University
University Hospital
Hospital
Chi-mei
Chi-mei Medical
Medical Center
Center Hospital
Hospital
Subject Information
Case
Control
Buccal Cell Collection Information
DATE: ____ / ____ / ____ TIME: ____ : ____
Date and time of collection:
Buccal cells collected by (NAME and English Initials): ______________________________________
Cup 0011
Collection Status
Collected
Not collected
Buccal Cell Receipt and Processing (complete if computer/Internet access is not available)
Buccal Cell Collection Receipt
Enter Date Received at lab: ____ / ____ / ____
Enter Time Received: ____ : ____
Specimen receipted by(NAME and English Initials): ____________________________
Receipt Condition
Received OK
Buccal Cell Processing
Buccal Cell Aliquots
Not received
Time Aliquotted: ____ : ____
Sequence Created
Sequence Created
0102
0101
Date buccal specimens or aliquots received at Study Center
(to be completed by Study Center)
D
Received by: ______________________________________________
Name
D
/
M
M
/
Y
Y
Y
Y
| File Type | application/pdf |
| Author | huw2 |
| File Modified | 2015-10-29 |
| File Created | 2015-10-14 |