Laboratory Reference Ranges
Laboratory Name
text
Lab Code
text
Date these reference ranges became effective
date
Age range low
float
Age range high
float
Age units
integer
Sex
text
Laboratory Reference Ranges - Haematology
Haematology - Test
integer
Haematology - Unit
text
Haematology - Low Reference Value
float
Haematology - High Reference Value
float
Laboratory Reference Ranges - Biochemistry
Biochemistry - Test
integer
Biochemistry - Unit
text
Biochemistry - Low Reference Value
float
Biochemistry - High Reference Value
float
Laboratory Reference Ranges - Hepatic Function
Hepatic function - Test
integer
Hepatic function - Unit
text
Hepatic function - Low Reference Value
float
Hepatic function - High Reference Value
float
Laboratory Reference Ranges - Renal Function
Renal function - Test
integer
Renal function - Unit
text
Renal function - Low Reference Value
float
Renal function - High Reference Value
float
Use of human samples by GSK
Use of human samples by GSK
text
Please tick below box if a 15 years GSK storage period is covered by the subject’s Informed Consent form of your center.
integer
Specify other storage period
text
Complete and submit a new form for each change during the study.
date
Investigator's Signature
Investigator's Signature
text
Printed Investigator's name
text
Investigator's signature date
date