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Appendix B Contributor's Consultation Request Form Joint Pathology Center As noted in the report text, the Joint Pathology Center uses a stan- dardized form for obtaining clinical data associated with the specimens submitted to it for consultation. What follows is a reproduction of the version of this form posted to the JPC website (www.jpc.capmed.mil/docs/ consultation_request_form.pdf) when the committee completed its work in mid-2012. The form is dated 03/30/2011. 141
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142 FUTURE USES OF THE DOD JPC BIOREPOSITORY ATTN: Armed Forces Institute of Pathology CONTRIBUTOR'S CONSULTATION REQUEST FORM CMAD 6825 16th Street NW ARMED FORCES INSTITUTE OF PATHOLOGY Bldg. 54, Room G071 Washington DC 20306-6000 PATIENT INFORMATION (Required) AFIP Accession No. (previous if known): LAST NAME FIRST MIDDLE INITIAL RACE American Indian or Alaskan Native Asian or Pacific Islander DATE OF BIRTH AGE SOCIAL SECURITY NO. Black White Unknown Month: Day: Year: SEX: Male Female ETHNICITY Hispanic Not of Hispanic Origin MATERIALS FORWARDED FIXATIVE (Required) REGISTRIES/SERS Clinical Information (req'd) Formalin Fixed (Wet Tissue) Frozen Tissue Formalin SERS Surgical Path Report (req'd) Autopsy Protocol X-rays B5 POW Slides (req'd) Rpt of Investigation (AFME) Photos Glyo-Fixx Kuwait/Persian Gulf Blocks Rpt of Toxicologic Studies Other Alcohol (eg: Omnifx* Iraqi Freedom (AFME) Safe-Fix*, Histochoice*) (*TM) Enduring Freedom CASE IDENTIFICATION Frozen (Afghanistan) Specific Biopsy Site or Organ (Required) Agent Orange Immunoflouresence SPECIMEN IDENTIFICATION EM Depleted Uranium Specimen Containers must be labeled with two identifiers. Leishmaniasis Other Embedded Metal Contributor's Accession No.(s) Zenkers, Bouins, etc. Fragments Requested Department Chemical Agent (nerve) Other CONTRIBUTOR'S WORKING DIAGNOSIS: (Differential diagnosis and questions should be entered in "Comments and Requests" Section) CLINICAL HISTORY: Include: Location, Size, Symptoms, Duration, Physical and Laboratory Findings, Type and Date of Operation(s) and/or other Treatment. (Continue in "Comment and Requests" section) CONTRIBUTOR'S INFORMATION CONTRIBUTOR'S NAME NAME OF FACILITY BUSINESS ADDRESS CITY STATE ZIP CODE COUNTRY TELEPHONE FAX EMAIL This form may be reproduced by the contributor or requested from AFIP. AFIP Form 288-R (October 2010)
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APPENDIX B 143 IMPORTANT Have you enclosed a legible summary of the clinical findings, laboratory data, operative findings or report, and specific treatment? Cases selected for inclusion in specific registries often require additional information. Clinical or gross photos, pertinent X-rays, CT scans, MRI scans, echograms, angiograms, and similar diagnostic studies add substantially to the education value of the case. They are highly desired by some departments and required by others. COMMENTS AND REQUESTS: AFIP RETENTION POLICY 1. MICROSCOPIC SLIDES SUBMITTED WITH EACH CASE ARE RETAINED PERMANENTLY. Under certain circumstances original slides may be returned to the Contributor if requested by the Contributor and approved by the Chair of the Department that would review the case. If slides are returned, then each slide will be digitized at the expense of the Contributor. 2. Blocks are retained for a minimum of ten (10) years, unless return is requested by the Contributor at the time the case is submitted. Contributors may request return or loan of blocks at some later time. If blocks are returned, then AFIP will retain representative diagnostic material. 3. Other pathologic material, X-rays, CT scans, MRI scans, echograms, angiograms, photographs, and similar diagnostic studies may be retained for education and research or discarded. SIGNATURE OF CONTRIBUTOR DATE REQUEST FORWARDED (YYYYMMDD) PRIVACY ACT STATEMENT 1. AUTHORITY: 5 U.S.C. 301 and 10 U.S.C 176, 5 U.S.C. 552a, 10 U.S.C 1079b. 2. PRINCIPAL PURPOSES: Medical information received is considered during the consultative process and is used to form a database for education and research in pathology. Other patient information is used for filing and retrieval of consultation records. Information concerning the contributor is used to maintain contributor mailing lists. 3. ROUTINE USES: a. In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained therein may specifically be disclosed outside the DoD as a routine use as follows. b. Pathology consultation records are tracked in the Pathology Information Management System database for filing and retrieval of records, medical research, and statistical purposes. Individual consultation records may be released to the contributing medical care provider (physician, veterinarian), when required by law or as otherwise permitted by 45 C.F.R. 164. c. The DoD `Blanket Routine Uses' set forth at the beginning of the Army's compilation of systems of records notices also apply to this system. d. Pathology consultation records contain individually identifiable health information. The DoD Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and Accountability Act of 1996, applies to most such health information. DoD 6025.18-R may place additional procedural requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in this Privacy Act Notice. 4. PROVISION OF INFORMATION: The provision of patient information requested on this form is voluntary. However, if the information is not furnished, a consultation may not be possible. If so, the material submitted may be returned at the discretion of the AFIP without a consultation.
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