Form 8 Attachment 10 Admin Form pathologist

For pathologist component of reporting 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.

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