The Pharmacogenomic Submission and Quality Assurance Form, a CDE-compliant CALGB CRF to be used on most CALGB protocols. Source Form: NCI FormBuilder:

  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/18/15 6/18/15 -
Uploaded on:

June 18, 2015

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Creative Commons BY-NC 3.0 Legacy
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CALGB: Pharmacogenomic Submission and Quality Assurance Form

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

Are data amended
Patient demographics
Biopsy specimen
Does specimen accompany this form
Specify reason (If no,)
Biopsy and Cytology Specimens collection
Sample type (Mark all that apply with an X.)
Was blood sample collected in an EDTA Vacutainer tube (purple top)
Was blood sample stored either at 4 degrees C or frozen within 24 hours of collection
Was buccal cell sample immediately submersed in 250 microliters of lysis buffer
Was buccal cell sample stored at -20 degrees C
Biopsy and Cytology Specimens shipment
Shipment type (Mark one with an X.)
Specify reason (If Dry ice,)

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