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ENSURE PRINT BACKGROUND COLOURS SETTING IS ON AND PAGE MARGINS ARE SET TO ZERO IN PRINTER SETUP

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[% END %] [% # INCLUDE dumper.tt dump = t FOREACH t IN ngis_tests %] [% IF requests.size; # requests is array of hashrefs; request_specimen # & results_summary are arrays (because many-to-one): FOREACH r IN requests; # INCLUDE dumper.tt dump = r; # reset local vars (as we're in a loop): sample_dispatched = ''; haemonc_category = ''; result_summary = ''; result_date = ''; patient = r.patient_case.patient; # germline requests use WGS as (sole) sample_type: is_germline = r.request_specimen.0.specimen.sample_code.match('WGS'); # get results_summary (from original_diagnosis 'test' if germline): result_summary = is_germline ? r.wgs_section_results.original_diagnosis : r.results_summary.0.results_summary; # sample_dispatched: sample_dispatched = r.wgs_section_results.sample_type; # ngis test codes: FOREACH t IN ngis_tests; # INCLUDE dumper.tt dump = t.as_tree; # TODO: how to link ngis_test_code to results_summary ? END; %]

Version 1.12

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Genomic Medicine Service
Whole Genome Sequencing (WGS) Test Request
PLEASE DO NOT USE FOR NON-WGS TESTS
Requesting organisation: [% r.patient_case.referral_source.display_name %]
GLH laboratory to receive sample: YNEGLH Leeds Central Lab Test Required
Whole Genome Sequencing
Patient first name: [% patient.first_name.ucfirst %]
Ethnicity (please tick on page 2)
Patient last name: [% patient.last_name.upper %]
Test Directory Clinical Indication & code
[% # TODO: this should be derived from ngis_lab_test data IF result_summary.match('myeloid'); 'M80.1'; ELSIF result_summary.match('lymphoblastic'); 'M91.1'; ELSIF result_summary.match('blastic plasmacytoid'); 'M90.1'; END; %]
Date of birth
[% patient.dob.dmy('/') %]
Hospital number
[% r.patient_case.unit_number %]
Gender
Male Female Other / Unknown
Presentation status
First diagnosis Recurrence/relapse Unknown
NHS number (or postcode if not known)
[% INCLUDE site/nhs_number.tt nhs_number = patient.nhs_number; %]
[% IF NOT patient.nhs_number %]
Reason NHS number not available:
Patient is a foreign national Other (provide reason)
[% END %]
Additional clinical information (if relevant)
eg previous tumours, molecular testing, and relevant treatment history with dates
Solid tumour requests only
Primary
Metastatic
Lymphoma
Unknown
Histopathology lab ID
Additional tumour information (if relevant)
eg site of metastasis (if metastatic), or unknown primary
Date of this diagnosis
dd/mm/yyyy
 Tumour topography Tumour morphology
[% # get haem-onc results (not germline samples): IF is_germline; # 'result summary: ' _ result_summary; # reset local vars (may have been set by previous req in loop) collection_date = ''; sample_type = ''; ELSE; result_date = r.results_summary.0.time.dmy('/'); IF result_summary.match('myeloid'); haemonc_category = 'AML'; ELSIF result_summary.match('lymphoblastic'); haemonc_category = 'ALL'; ELSE; haemonc_category = 'other'; END; # 'haemonc_category:' _ haemonc_category; END; %]
Haemato-oncology liquid tumour requests only
AML ALL Other (please specify) [% result_summary IF haemonc_category.match('other') %]
Local sample ID
[% UNLESS is_germline; INCLUDE site/lab_number.tt data = r; END %]
Date of this diagnosis
[% result_date %]
[% # not for germline samples: IF is_germline; # reset local vars (may have been set by previous req in loop) collection_date = ''; sample_type = ''; ELSE; collection_date = r.request_specimen_detail.specimen_date; sample_type = sample_dispatched.match('blood|marrow|tissue') ? sample_dispatched : 'other'; END; %]
Complete for tumour samples
Fresh frozen tumour Bone marrow Blood (EDTA) Other (please specify): [% sample_dispatched IF sample_type.match('other') %]
% malignant nuclei / blasts or equivalent in this sample (refer to sample handling guidance) must be provided below
Local sample tube ID Collection date / time % malignant nuclei / blasts nucleated cell count volume required
[% collection_date.strftime('%d/%m/%Y %H:%M') %] x109/L µL
[% IF is_germline; # only for germline samples: # will do unnecessary db lookup if rsd is null, but can't use # as_tree - see top of file collection_date = r.request_specimen_detail.specimen_date; sample_type = sample_dispatched.match('blood|saliva|fibroblast|skin') ? sample_dispatched : 'other'; ELSE; # reset local vars (may have been set by previous req in loop) collection_date = ''; sample_type = ''; END; %]
Complete for germline samples
Blood (EDTA) Saliva Fibroblasts Skin biopsy Other (please specify): [% sample_dispatched IF sample_type.match('other') %]
Local sample ID Collection date / time Sample volume if applicable Comments
[% IF is_germline; INCLUDE site/lab_number.tt data = r; END %]
[% collection_date.strftime('%d/%m/%Y %H:%M') %]
Consultant details
Responsible consultant: [% r.referrer_department.referrer.name %]
Department: [% r.referrer_department.hospital_department.display_name %]
Phone:
Email:
Main contact (if different from responsible consultant)
Name:
Department:
Phone:
Email:
I have attached a copy of the Record of Discussion form
Patient conversation taken place, Record of Discussion form to follow
[% patient.first_name.ucfirst %] [% patient.last_name.upper %] :: [% patient.dob.dmy('/') %] :: [% patient.nhs_number OR r.patient_case.unit_number %] (page 2 of 2)

Ethnicity - Please tick the relevant self defined ethnicity code below

White Mixed Asian or Asian British Black or Black British Other Ethnic Group
A British D White and Black Caribbean H Indian M Caribbean R Chinese
B Irish E White and Black African I Pakistani N African S Any other ethnic group
C Any other White background F White and Asian J Bangladeshi O Any other Black background
G Any other mixed background L Any other Asian background Z Not stated
Additional local identifiers - please use the table below, these will also be displayed in the interpretation panel
Type - O (Test order/Case ID), P (local patient ID), S (local sample identifier)
Organisation Type Identifier
[% END; ELSE # no requests: %]

No outstanding WGS requests

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