HEM Source Form: NCI FormBuilder:

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  2. 5/28/15 5/28/15 -
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May 28, 2015

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Creative Commons BY-NC 3.0 Legacy
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Header Module
Record Neutrophil Count And Specimen Collection Dates
Did the patient achieve ANC recovery =>500/mm3 on three consecutive
Record Chimerism Assay Data For Marrow And/or Blood
Was a chimerism performed on a marrow sample
Method of evaluation
Cell type
Marrow assay results
T Cell Chimerism
Was a chimerism performed on a T cell sample
Type of sample
T cell assay results
Did the patient achieve a stem cell re-infusion due to inadequate hematopoietic function

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