LABORATORY REFERENCE RANGES
LABORATORY NAME:
text
For internal use only
text
Enter the reference range for each test. If the reference ranges for any test differ by age range, age units or sex, complete a separate form for each variation (e.g., males 0-16, males 17-99, females 0- 16, females 17-99 years).
date
Age range
integer
Low age range
integer
High age range
integer
tick one box
text
Sex
text
Hematology
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Basophils
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Blood Chemistry
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
Unit
text
Low Reference Value
text
High Reference value
text
USE OF HUMAN SAMPLES BY GSK
Use of Human Samples by GSK
text
This may include the management of the quality of these current tests, the maintenance or improvement of these current tests, the development of new test methods for the markers described in the protocol as well as making sure that new tests are comparable to previous methods and work reliably.
boolean
These investigations excludes genetics and HIV testing.
boolean
These investigations excludes genetic and HIV testing. Investigator will always ask in advance the permission of the independent Ethics Committee/Institutional Review Board linked to the institution where this research is performed.
boolean
This research excludes genetic and HIV testing and does not affect subject participation in the study.
boolean
a 15 years GSK storage period
text
Specify Other
text
Complete and submit a new form for each change during the study.
date
INVESTIGATOR'S SIGNATURE