7 Form

The Framingham Heart Study

LABORATORY

CELL LINE VENIPUNCTURE FORM

PARTICIPANT INFORMATION

Cohort

Offspring

Gen3

Omni Gen2

NOS

ID: ____ - _________

Exam: ____________

Name: _________________________________________________________________

Date: ____ / ____ / ____

0 = clinic	4 = remote
1 = home visit	5 = osteo
2 = nursing home	6 = blood only
3 = hospital	7 = other

Type of Appointment: _______

Comments: _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

PHLEBOTOMIST USE ONLY

Phlebotomist Name: ______________________________________________________

Date of Blood Draw: ____ / ____ / ____

Samples Obtained: Yes No Number of tubes: ____________________

If blood draw only; Consent received: Yes No

Comments: _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Numbers for Participants who are alive and do not have a successful cell line through October 31, 2007.

 

 

                                             Cumulative           Cumulative

          IDTYPE    Frequency     Percent               Frequency         Percent

          -------------------------------------------------------------------------------------------------------

Original           93                  11.80                 93                    11.80

Offspring          642                  81.47                735                   93.27

 Gen 3         53                   6.73                 788                   100.00

 

File: WS.005.vpform.doc Approved:

Version: 06.23.2005 Date: