Form 5 Interviewer Administrative Forms

OMB #: 0925-XXXX
Expiration date: XX/XX/20XX
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-XXXX). 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

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 _ _ _ _ _

]

[

/

R

/

/

C

C

o

o

]

[

R

[

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-XXXX
Expiration date: XX/XX/20XX
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-XXXX). Do not return the completed form to this address.

Control Selection Record

Control Selection Record

1. Characteristics of Case Requiring a Matching Control:

Case Subject ID:
a) Gender:
b) Date of Birth/Age:
c) Hospital:
d) Enrollment Date:

AS-c

Control Matching Criteria:

cccc

M  F 
_____________________
_____________________
_____________________

Same gender
Within +/- 5 years of age
From the same hospital as the case
Within +3 months of case enrollment

(dd/mm/yyyy):
e) Area of Residence:
f) Resident of Core Geographic

Region for at least 15 years?

_______________________
Yes  No 

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-XXXX
Expiration date: XX/XX/20XX
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-XXXX). 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-XXXX
Expiration date: XX/XX/20XX
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-XXXX). 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-XXXX
Expiration date: XX/XX/20XX
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-XXXX). 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

For interviewer component of the reporting form:
OMB #: 0925-XXXX
Expiration date: XX/XX/20XX
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-XXXX). Do not return the completed form to this address.

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