Document 1QYawQ8n5g95RK8J2ZdQEVyGq

Study ID Number _ _ _ __ Name _ _ __ 3. Other cancers (specify if type known)_________ 4. Aplastic anemia 5. Myelodysplastic syndrome 6. Other blood disorders (specify what if known) Version 24 February 2004 CC_DP Questionnaire 4 of 15 SH ELL-MCCLU RG-059282