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DIAGNOSTIC REPORT FORMS

FOR LABKEY ENTRY


MESA ICEMR
KGVK
ARMD PROTOCOL
15
th
JANUARY, 2013

MALARIA EVOLUTION IN SOUTH ASIA RESEARCH CENTER
KGVK ARMD Protocol 01/15/13 v1
Diagnostics Data Report Forms
2



DIAGNOSTICS PAGE 1 INSTRUCTION KEY
Follow Patient Sample Protocols for instructions on experiments

Date of Measurement
Enter the date that the sample was analyzed as MM/DD/YYYY.

Time of Measurement
Enter the time that the sample was analyzed with the 12 hour clock,circling
AM or PM. Enter the value to the closest 15 minute period.

Scientist
Enter the first and last name of the scientist who did the analysis.

Patient
Enter the Patient ID as XX/XX/XXXX.

Processing Protocol
Enter the processing protocol with two digits. If uncertain about the protocol
used, enter 99.

Initial % Parasitemia
Enter the initial % parasitemia as XX.XX%. If the % parasitemia was not
measured, enter 88.88. If the % parasitemia is uncertain, enter 99.99.

Parasite Density
Enter the parasite density in parasites/L. If the parasite density was not
measured, enter 88888888 (eight 8s). If the parasite density was uncertain,
enter 99999999 (eight 9s).

Initial Gametocytemia
Enter the initial % gametocytemia as XX.XX%. If the % gametocytemia was
not measured, enter 88.88. If the % gametocytemia was uncertain, enter
99.99.

Gametocyte Density
Enter the gametocyte density in gametocytes/uL. If the gametocyte density
was not measured, enter 88888888 (eight 8s). If the gametocyte density was
uncertain, enter 99999999 (eight 9s).

MALARIA EVOLUTION IN SOUTH ASIA RESEARCH CENTER
KGVK ARMD Protocol 01/15/13 v1
Diagnostics Data Report Forms
3



Diagnostics Page 1


Diagnostics
1. Date of measurement __ __ / __ __ / __ __ __ __
2. Time of measurement
(circle either AM or PM)
___ ___ : ___ ___ AM/PM
3. Scientist _______________________
4. Patient ID __ __ / __ __ / __ __ __ __
5. Processing Protocol ____ ____
6. Initial % Parasitemia __ __ . __ __ %
7. Parasite Density (parasites/L) __ __ __ __ __ __ __ __
8. Initial % Gametocytemia __ __ . __ __ %
9. Gametocyte Density (gametocytes/L) __ __ __ __ __ __ __ __

MALARIA EVOLUTION IN SOUTH ASIA RESEARCH CENTER
KGVK ARMD Protocol 01/15/13 v1
Diagnostics Data Report Forms
4



DIAGNOSTICS PAGE 2 INSTRUCTION KEY
Follow Patient Sample Protocols for instructions on experiments

Hemoglobin
Enter the hemoglobin value as XX.X g/dL. If the hemoglobin value was not
determined, enter 00.0. If the hemoglobin value was uncertain, enter 99.9.

Hematocrit
Enter the hematocrit value as XX%. Enter 00 when the hematocrit was not
measured. Enter 99 when the hematocrit is uncertain.

Thick blood smear
Enter the species infection as determined from the thick blood smear. Write
Pf for P. falciparum, Pv for P. vivax, mixed for missed infections and negative
for no malaria infection.
If the blood smear was not read, write n/a.

Thin blood smear
Enter the species infection as determined from the thin blood smear. Write Pf
for P. falciparum, Pv for P. vivax, mixed for missed infections and negative for
no malaria infection.
If the blood smear was not read, write n/a.

RDT
Enter the species infection as determined from the RDT. Write Pf for P.
falciparum, Pv for P. vivax, mixed for missed infections and negative for no
malaria infection.
If the RDT was not read, write n/a.

FreezerPro IDs
Enter the FreezerPro ID numbers for any aliquots stored after sample
processing. This includes RDTs, slide boxes, FTA cards, plasma, white blood
cells and all stored pRBCs.

MALARIA EVOLUTION IN SOUTH ASIA RESEARCH CENTER
KGVK ARMD Protocol 01/15/13 v1
Diagnostics Data Report Forms
5



Diagnostics Page 2


Diagnostics
10. Hemoglobin (g/dL) ___ ___ . ___
11. Hematocrit (%) ____ ____ %
12. Thick blood smear _______________________
13. Thin blood smear _______________________
14. RDT _______________________
15. FreezerPro IDs _______________________
_______________________