CALGB: DIAGNOSTIC BLOOD/BONE MARROW EVALUATION FORM Daunorubicin and Cytarabine With or Without Oblimersen in Treating Older Patients With Previously Untreated Acute Myeloid Leukemia Source Form: NCI FormBuilder:

  1. 9/19/12 9/19/12 -
  2. 7/9/15 7/9/15 - Martin Dugas
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July 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Leukemia Lab BLOOD/BONE MARROW EVALUATION FORM 2076614v3.0 NCT00085124

Instructions: This form is to be completed and submitted with each bone marrow or blood sample drawn for evaluation. Unless otherwise indicated use ?-1? to indicate that and answer is ?unknown,? ?unobtainable,? ?not applicable? or ?not done.? Make 2 copies, send original to reference laboratory with sample; send one copy to CALGB Statistical Center, Data Operations and keep a copy for your records.

Ccrr Module For Calgb: Diagnostic Blood/bone Marrow Evaluation Form
Did patient have prior MDS?
Is this therapy-related AML?
Source of specimen submitted (specimens must be submitted within one week of date sample obtained)
Type of sample
CBC report (including WBC, hemoglobin, platelet count)
Flow cytometry/immunophenotype report
Pathology report
Cytogenetics report

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