Form ProdForm Product Form

OMB No: 0915Expiration Date:

Public Burden Statement

Public Burden Statement: An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid
OMB control number. The OMB control number for this project is
. Public
reporting burden for this collection of information is estimated to average 1.5 hours per
response, including the time for reviewing instructions, searching existing data sources,
and completing and reviewing the collection of information. Send comments regarding
this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers
Lane, Room 10-33, Rockville, Maryland, 20857.

CIBMTR Center Number:
CIBMTR Recipient ID:
-

NMDP Donor ID:

Hematopoietic Stem Cell
Transplant (HSCT) Infusion

-

NMDP Cord

Non-NMDP
Blood Unit ID:
cord blood unit *
* For non-NMDP cords, see page 11 to report CBU ID and donor demographics.

2 0

Today’s Date:

Registry Use Only

Month

Day

Year

Date of HSCT for which this form is
being completed: 

Sequence
Number:

HSCT type:
(check only one)

Date
Received:

autologous

2 0
Month

allogeneic,
unrelated

Day

Year

allogeneic,
syngeneic
related

(identical twin)

other product,
Product type:
marrow
PBSC
cord blood
(check only one)

multiple cord
specify:
blood units infused

This form must be completed for all recipients who receive a HSCT product. If more than one type of HSCT product
is infused, each product type must be analyzed and reported separately.
Questions followed by the symbol  indicate additional information necessary to complete the question is
referenced in the forms instruction manual; A indicates an appendix.
A series of collections should be considered a single product when they are all from the same donor and use the
same collection method and technique (and mobilization, if applicable), even if the collections are performed on
different days.

Pre-Collection Therapy
1. Did the donor receive treatment, prior to any stem cell harvest, to enhance the product collection for this HSCT?
(If the HSCT product was from an NMDP donor, or the product is a cord blood unit, then continue with question 20.)
1
yes
Specify treatment(s): (select all that apply)
2
no
2. 1
yes 2
no (autologous only)
3
NMDP
Report details on disease-specific insert
Chemotherapy
donor
3. 1
yes 2
no (autologous only)
Anti-CD20 (rituximab,
Report details on disease-specific insert
Rituxan)
Continue with
question 24
4

4.

1

yes

2

no Growth factor(s)

cord blood

If yes, specify growth factor(s):
5.
6.
7.

unit

yes
1
yes
1
yes
1

no G-CSF
2
no GM-CSF
2
no Other
2

8. Specify:

Continue with
question 24
9.

1

yes

2

no Other treatment

10. Specify treatment:

CIBMTR Form 2006 (INF) v1.0 (1–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

Mail this form to your
designated campus (Milwaukee
or Minneapolis). Retain the
original at the transplant center.

CIBMTR Center Number:

CIBMTR Recipient ID:

Product Collection

2 0

11. Date of product collection:
Month

Day

Year

12. Was more than one collection required for this HSCT? 
1
yes
13. Specify the number of subsequent days of collection in this episode:
2
no
Complete a separate product form for each subsequent collection that was not part of this
mobilization.
14. Were anticoagulants added to the product during collection?
1
yes
Specify anticoagulant(s):
2
no
15. Acid citrate dextrose (ACD)
1
yes
2
no
16. Citrate phosphate dextrose (CPD)
1
yes
2
no
17. Heparin
1
yes
2
no
18. Other anticoagulant
1
yes
2
no

19. Specify other anticoagulant:

Product Transport and Receipt
20. Was this product collected off-site and shipped to your facility?
1
yes
21. Date of receipt of product at your facility:
2
no

2 0
Month

22. Time of receipt of product (24-hour clock):

Day

:
Hour

Year
1

Minute

2

standard time

daylight savings time

23. Specify the shipping environment of the product(s):
1
frozen gel pack
2
frozen cord blood unit(s)
3
room temperature per transplant center request
4
other
24. Specify shipping environment:
temperature
25. (Cord blood product only) Were the secondary containers (e.g., insulated shipping containers and
unit cassette) intact when they arrived at your center?
1
yes
2
no

CIBMTR Form 2006 (INF) v1.0 (2–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

CIBMTR Center Number:

CIBMTR Recipient ID:

26. (Cord blood product only) Was the cord blood unit completely frozen when it arrived at your
center?
1
yes
2
no
27. (Cord blood product only) Was the cord blood unit stored at your center prior to thawing?
1
yes
28. Specify the storage method used for the cord blood unit:
2
no
1
liquid nitrogen
2
vapor phase
3
electric freezer
29. Temperature during storage: —

°C

2 0

30. Date storage started:
Month

Day

Year

Product Processing / Manipulation
31. Was a fresh product received, then cryopreserved at your facility prior to infusion?
1
yes
2
no
3
not applicable, cord blood unit
32. Was the product thawed from a cryopreserved state prior to infusion?
1
yes
33. Was the entire product thawed?
2
no
1
yes
2
no
34. Was a compartment of the bag thawed?
1
yes
2
no
35. Were there multiple product bags?
1
yes
36. Specify number of bags thawed:
2
no

2 0

37. Date thawing process initiated:
Month

Day

38. Time at initiation of thaw (24-hour clock):

Year
1

:
Hour

39. Time at completion of thaw (24-hour clock):

Minute

1

:
Hour

2

Minute

2

standard time

daylight savings time

standard time

daylight savings time

40. Was the primary container (e.g., cord blood unit bag) intact upon thawing?
1
yes
2
no

CIBMTR Form 2006 (INF) v1.0 (3–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

CIBMTR Center Number:

CIBMTR Recipient ID:

41. What method was used to thaw the product?
1
no wash — thawed at bedside, then infused
2
DMSO dilution — thawed in lab (added dextran and albumin), then infused
3
washed — thawed in lab (added dextran and albumin), spun and reconsituted in dextran
albumin, then infused
4
other
42. Specify other thaw method:
method
43. Did any adverse events or incidents occur while thawing the product?
1
yes
2
no
44. Was the product manipulated prior to infusion?
1
yes
45. Specify portion manipulated:
2
no
1
entire product
2
portion of product
If autologous
product, continue
with question 92;
if allogeneic
product, continue
with question 141.

Specify all methods used to manipulate the product:
46. ABO incompatibility (RBC depletion)
1
yes
Specify method:
2
no
47. 1
yes 2

48. 1
yes 2

49. 1
yes 2

50. 1
yes 2

51. 1
yes 2

52. 1
yes 2

no
no
no
no
no
no

Buffy coat preparation
Cell separator (i.e., COBE Spectra)
Density gradient separation (i.e., Ficoll)
Plasma removal
Sedimentation (i.e., hetastarch)
Other
53. Specify:

54. Ex-vivo expansion
1
yes
2
no
55. Genetic manipulation (gene transfer / transduction)
1
yes
2
no
56. Volume reduction
1
yes
2
no
57. CD34+ selection 
1
yes
58. Specify cell selection system used:
2
no
1
CliniMACS / CliniMax
2
Isolex
59. Specify system:
3
other

CIBMTR Form 2006 (INF) v1.0 (4–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

CIBMTR Center Number:

CIBMTR Recipient ID:

60. T-cell depletion
1
yes
2
no

71. Other
manipulation
1
yes
2
no

Specify method:
61. 1
yes 2
no antibody affinity column
62. 1
yes 2
no antibody coated plates
63. 1
yes 2
no antibody coated plates
and soybean lectin
64 1
yes 2
no antibody + complement
65. 1
yes 2
no antibody + toxin
66. 1
yes 2
no immunomagnetic beads
67. 1
yes 2
no elutriation
68. 1
yes 2
no CD34 affinity column plus sheep
rosetting 
70. Specify:
69. 1
yes 2
no other

Report the
antibodies
used for T-cell
depletion at
question 73.

red blood cell

72. Specify:

73. Were antibodies used during product manipulation?
1
yes
Specify antibodies:
2
no
74. 1
yes 2
no anti CD2
75. 1
yes 2
no anti CD3
76. 1
yes 2
no anti CD4
77. 1
yes 2
no anti CD5
78. 1
yes 2
no anti CD6
79. 1
yes 2
no anti CD7
80. 1
yes 2
no anti CD8
81. 1
yes 2
no anti CD34
82. 1
yes 2
no anti TCR alpha / beta (T10-B9)
83. 1
yes 2
no OKT-3
85. Specify:
84. 1
yes 2
no other CD3
86.

1

yes

2

no anti CD52

Specify antibodies:
yes

87.
88.
89.
90.

1

yes

2

no other
antibody

CIBMTR Form 2006 (INF) v1.0 (5–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

1

1

1

no

campath-NOS
2
campath-1G
2
campath-1H
2

91. Specify:

CIBMTR Center Number:

CIBMTR Recipient ID:

Autologous Products Only
The following section refers to autologous products only, including autologous cord blood; if this is not an autologous
HSCT, continue with the Product Analysis section at question 141.
92. Were tumor cells detected in the recipient or autologous product prior to HSCT?
1
yes
Specify tumor cell detection method used, and site(s) of tumor cells:
2
no
93. Routine
histopathology
Specify site(s):
1
yes
94. 1
yes 2
no 3
not tested Circulating blood cells
2
no
95. 1
yes 2
no 3
not tested Bone marrow, in the interval
between last systemic therapy
and collection
97. Polymerase
96. 1
yes 2
no 3
not tested Collected cells, before purging
chain reaction
(PCR)
Specify site(s):
1
yes
98. 1
yes 2
no 3
not tested Circulating blood cells
2
no
99. 1
yes 2
no 3
not tested Bone marrow, in the interval
between last systemic therapy
and collection
100.
1


yes
2


no
3


not
tested
Collected
cells, before purging
101. Other molecular
technique
1
yes
102. Specify method:
2
no
Specify site(s):
103. 1
yes
104. 1
yes

106. Immunohistochemistry
1
yes
2
no

110. Cell culture
technique
1
yes
2
no

3

not tested Circulating blood cells

not tested Bone marrow, in the interval

no

3

between last systemic therapy
and collection

not tested Collected cells, before purging

Specify site(s):
107. 1
yes 2
no
108. 1
yes 2
no

3

105. 1
yes

2

2

no

no

3

3

not tested Circulating blood cells

not tested Bone marrow, in the interval

no

3

between last systemic therapy
and collection

not tested Collected cells, before purging

Specify site(s):
111. 1
yes 2
no
112. 1
yes 2
no

3

109. 1
yes

113.
114. Other technique
1
yes
2
no

2

1

yes

2

2

no

3

not tested Circulating blood cells

not tested Bone marrow, in the interval

3

between last systemic therapy
and collection

not tested Collected cells, before purging

115. Specify method:
Specify site(s):
116.
117.

1
1

CIBMTR Form 2006 (INF) v1.0 (6–13) July 2007 Draft 04/20/2007
118. 1
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

yes

yes

yes

2
2

2

no

no

no

3

not tested Circulating blood cells

not tested Bone marrow, in the interval

3

between last systemic therapy
and collection

not tested Collected cells, before purging

3

For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

CIBMTR Center Number:

CIBMTR Recipient ID:

119. Was the product treated to remove malignant cells (purged)? (autologous product only)
1
yes
Specify method(s) used:
2
no
121. If yes, specify:
120. 1
yes 2
no Monoclonal antibody
122. 1
123. 1
124. 1
126. 1
127 1
128. 1

yes

yes

yes

yes

yes

yes

130. 1
yes

no
2
no
2
no
2
no
2
no
2
no
2

2

4-hydroperoxycyclophosphamide (4HC)
Mafosfamide
125. If yes, specify:
Other drug
Elutriation
Immunomagnetic column
129. If yes, specify:
Toxin

no Positive stem cell selection
(other than preparation
of mononuclear
fraction)

132. 1
yes

2

no Other method

131. If yes, specify method:
133. If yes, specify:

Specify if tumor cells were detected in the graft after purging by each method used:
134. 1
yes 2
no 3
not tested Routine histophathology
135. 1
yes 2
no 3
not tested Polymerase chain reaction (PCR)
136. 1
yes 2
no 3
not tested Other molecular technique
137. 1
yes 2
no 3
not tested Immunohistochemistry
138. 1
yes 2
no 3
not tested Cell culture technique
139. 1
yes 2
no 3
not tested Other
140. If yes, specify:

Product Analysis (All Products) 
Report product analysis results under each timepoint that testing was performed. If more than two analyses were
performed, copy and complete pages 7–8 for each additional analysis.
Product Analysis at 1st Timepoint
Specify the timepoint in 141.
the product preparation
phase that the product
was analyzed:

1
2

3
4
5

product arrival

post-processing,

162.

2 0
Month

Day

3
4
5

1
2

mL

g

CIBMTR Form 2006 (INF) v1.0 (7–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

product arrival

post-processing,
pre-cryopreservation /
manipulation 

post-thaw

post-manipulation

at infusion (final quantity infused)

2 0

163.

Year

•

1
2

pre-cryopreservation /
manipulation 

post-thaw

post-manipulation

at infusion (final quantity infused)

Date of product analysis: 142.

Total volume of product: 143.

Product Analysis at 2nd Timepoint

Month

164.

Day

Year
1

•

2

mL

g

CIBMTR Center Number:

CIBMTR Recipient ID:

Product Analysis at 1st Timepoint

Product Analysis at 2nd Timepoint

In this section, report the total number of cells (not cells per kilogram).
Total Number
Nucleated cells:

144.

Mononucleated cells:

145.

•
•

Nucleated red blood cells: 146.
CD34+ cells:

147.

CD3+ cells:

148.

CD4+ cells:

149.

CD8+ cells:

150.

Viability of cells:

151.

Method of testing cell
viability:

152.

•
•
•
•
•




3

4

2

not tested 165.

x 10

not tested 166.

x 10

not tested 167.

x 10

not tested 168.

x 10

not tested 169.

x 10

not tested 170.

x 10

not tested 171.

7-AAD
propidium iodide
trypan blue
other method

Exponent

•
•
•
•
•
•
•

172.
173.

3

4

1

x 10

not tested

x 10

not tested

x 10

not tested

x 10

not tested

x 10

not tested

x 10

not tested

x 10

not tested

not tested

%

2

Specify other method: 153.
Were the colony-forming 154.
units (CFU) assessed
after thawing?
(cord blood product only)

Total Number

x 10

not tested

%
1

Exponent

7-AAD
propidium iodide
trypan blue
other method

174.

yes
2
no

Continue with question 155

1

yes

175.

Continue with question 158

no

Continue with question 176

yes

Continue with question 179

no

Was there growth?

155.

Total colonies per
product:

156.

•

x 105

unknown

177.

•

x 105

unknown

Total CFU-GM:

157.

•

x 105

unknown

178.

•

x 105

unknown

Were cultures performed 158.
before infusion to test the
product(s) for bacterial or
fungal infection?
(complete for all cell products)
Specify results:

159.

1

2

yes
2
no
1

1

positive

176.

yes
2
no
1

Continue with question 159

179.

Continue with question 162

2

negative

3

unknown

180.

Specify organism
160.
code(s):
(see page 9 for codes)

181.

If code 198, 209,
219, or 259, specify
organism:

182.

161.

CIBMTR Form 2006 (INF) v1.0 (8–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

1

2

yes
2
no
1

1

positive

Continue with question 180
Continue with question 183

2

negative

3

unknown

CIBMTR Center Number:

CIBMTR Recipient ID:

Codes for Commonly Reported Organisms
Bacterial Infections
121 Acinetobacter
122 Actinomyces
123 Bacillus
124 Bacteroides (gracillis,
uniformis, vulgaris, other
species)
125 Bordetella pertussis
(whooping cough)
126 Borrelia (Lyme disease)
127 Branhamella or Moraxella
catarrhalis (other species)
128 Campylobacter (all species)
129 Capnocytophaga
171 Chlamydia pneumoniae
172 Other chlamydia, specify
113 Chlamydia, NOS
130 Citrobacter (freundii, other
species)
131 Clostridium (all species
except difficile)
132 Clostridium difficile
173 Corynebacterium jeikeium
133 Corynebacterium (all nondiptheria species)
101 Coxiella
134 Enterobacter
177 Enterococcus, vancomycin
resistant (VRE)
135 Enterococcus (all species)
136 Escherichia (also E. coli)
137 Flavimonas oryzihabitans
138 Flavobacterium

139 Fusobacterium
144 Haemophilus (all species,
including influenzae)
145 Helicobacter pylori
146 Klebsiella
147 Lactobacillus (bulgaricus,
acidophilus, other species)
102 Legionella
103 Leptospira
148 Leptotrichia buccalis
149 Leuconostoc (all species)
104 Listeria
150 Methylobacterium
151 Micrococcus, NOS
112 Mycobacterium avium–
intracellulare (MAC, MAI)
174 Mycobacterium species
(cheloneae, fortuitum,
haemophilum, kansasii,
mucogenicum
110 Mycobacterium tuberculosis
(tuberculosis, Koch bacillus)
175 Other mycobacterium,
specify
176 Mycobacterium, NOS
105 Mycoplasma
152 Neisseria (gonorrhoea,
meningitidis, other species)
106 Nocardia
153 Pasteurella multocida
154 Propionibacterium (acnes,
avidum, granulosum, other
species)

155 Proteus
156 Pseudomonas (all species
except cepacia &
maltophilia)
157 Pseudomonas or
Burkholderia cepacia
158 Pseudomonas or
Stenotrophomonas or
Xanthomonas maltophilia
159 Rhodococcus
107 Rickettsia
160 Salmonella (all species)
161 Serratia marcescens
162 Shigella
163 Staphylococcus, coagulase
negative (not aureus)
164 Staphylococcus aureus
165 Staphylococcus, NOS
166 Stomatococcus
mucilaginosis
167 Streptococcus (all species
except Enterococcus)
178 Streptococcus pneumoniae
168 Treponema (syphilis)
169 Vibrio (all species)
197 Multiple bacteria at a single
site, specify bacterial codes
198 Other bacteria, specify ‡
501 Suspected atypical bacterial
infection
502 Suspected bacterial
infection

Fungal Infections
200 Candida, NOS
201 Candida albicans
206 Candida guillermondi
202 Candida krusei
207 Candida lusitaniae
203 Candida parapsilosis
204 Candida tropicalis
205 Candida (Torulopsis)
glabrata
209 Other Candida, specify ‡
210 Aspergillus, NOS
211 Aspergillus flavus
212 Aspergillus fumigatus
213 Aspergillus niger
219 Other Aspergillus, specify ‡
220 Cryptococcus species
230 Fusarium species
261 Histoplasmosis
240 Zygomycetes, NOS
241 Mucormycosis
242 Rhizopus
250 Yeast, NOS
259 Other fungus, specify ‡
260 Pneumocystis (PCP / PJP)
503 Suspected fungal infection

‡ The codes for “other organism, specify” (codes 198, 209, 219 and 259) should rarely be needed; check with your microbiology lab
or HSCT physician before using them.

Product Infusion
183. Was more than one product infused? (e.g., marrow and PBSC, PBSC and cord blood, two different cords, etc.)
1
yes
184. Was the product infusion described on this insert intended to produce hematopoietic
2
no
engraftment?
1
yes
185. Date of this product infusion:
2
no

2 0

Month

1

:

186. Time product infusion initiated (24-hour clock):
Hour

Minute

1

:

187. Time product infusion completed (24-hour clock):
Hour

2

Minute

2

Day

standard time

daylight savings time

standard time

daylight savings time

CIBMTR Form 2006 (INF) v1.0 (9–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

Year

CIBMTR Center Number:

CIBMTR Recipient ID:

188. Total volume of product plus additives infused:

•

mL

189. Specify the route of product infusion:
1
intravenous
2
intramedullary
3
intraperitoneal
4
other route of
190. Specify route of infusion:
infusion
191. Did the volume of infused product include any added agents?
1
yes
Specify agent(s) added:
2
no
192. 1
yes 2
no ACD
193. 1
yes 2
no Albumin
194. 1
yes 2
no Antibiotic
195. 1
yes 2
no Dextran
196. 1
yes 2
no Heparin
197. 1
yes 2
no Other

198. Specify agent:

199. Was the entire volume of product infused?
1
yes
200. Specify what happened to the reserved portion:
2
no
1
discarded
2
cryopreserved for future use
3
other fate
201. Specify:

The following questions refer to all stem cell products except for autologous marrow or autologous PBSC products.
If this HSCT used an autologous marrow or autologous PBSC product, continue with question 298.
202. Were there any adverse events or incidents associated with the stem cell infusion?
1
yes
Specify the following adverse event(s):
2
no

Required Medical
Intervention?

Adverse Event

203. 1
206. 1
209. 1
212. 1

yes

yes

yes

yes

215. 1
yes
218. 1
221. 1
224. 1
227. 1
230. 1
233. 1

yes

yes

yes

yes

yes

yes

236. 1
yes
239. 1
yes
242. 1
yes

no
2
no
2
no
2
no
2

2

no

no

no
2
no
2
no
2
no
2
no
2
2

Brachycardia
Chest tighness / pain
Chills at time of infusion
Fever ≤ 103° F within 24
hours of infusion
Fever > 103° F within 24
hours of infusion
Gross hemoglobinuria
Headache
Hives
Hypertension
Hypotension
Hypoxia requiring oxygen
(O2) support

no Nausea

no Rigors, mild
2
no Rigors, severe
2
2

CIBMTR Form 2006 (INF) v1.0 (10–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

yes
1
yes
1
yes

204.
207.
210.

1

213.

1

216.
219.
222.
225.
228.
231.

1

yes

yes
1
yes
1
yes
1
yes
1
yes
1
yes

yes
237. 1
yes
240. 1
yes
243. 1
yes
234.

1

Resolved?

no
2
no
2
no

205.
208.
211.

1

no

214.

1

2

no
2
no
2
no
2
no
2
no
2
no

217.
220.
223.
226.
229.
232.

1

no
2
no
2
no
2
no

235.

2

2

2

yes
1
yes
1
yes

yes

yes
1
yes
1
yes
1
yes
1
yes
1
yes

yes
238. 1
yes
241. 1
yes
244. 1
yes
1

no
2
no
2
no
2

2

no

no
2
no
2
no
2
no
2
no
2
no
2

no
2
no
2
no
2
no
2

CIBMTR Center Number:

CIBMTR Recipient ID:

Required Medical
Intervention?

Adverse Event

245. 1
248. 1
251. 1
254. 1

yes

yes

yes

yes

258. 1
yes

no

no
2
no
2
no
2
2

2

Shortness of breath (SOB) 246.
Tachycardia
249.
Vomiting
252.
Other expected AE
255. Specify:
256.

no Other unexpected AE
259. Specify:
260.

yes

yes
1
yes

Resolved?

no

no
2
no

247.
250.
253.

1

2

1

2

1

2

1

2

yes

yes
1
yes

no

no
2
no

1

yes

2

no

257.

1

yes

2

no

1

yes

2

no

261.

1

yes

2

no

262. In the Medical Director's judgement, was the adverse event a direct result of the infusion?
1
yes
263. Specify the most likely cause of the adverse event:
2
no
1
regimen related
2
product reaction
3
drug reaction
4
other illness
264. Specify illness:
5

other reason

265. Specify reason:

Donor Demographic Information
This Donor Demographic Information section (questions 266–287) is to be completed for all stem cell donors except
NMDP donors, NMDP cord blood units, and autologous marrow or PBSC donors. If the stem cell product was from an
NMDP donor or an autologous marrow or PBSC donor, continue with question 298.

date unknown

266. Donor’s date of birth:
Month

Day

Year

267. (Cord blood unit only) Age of mother (approximate):

years

age unknown

268. (Cord blood unit only) Non-NMDP cord blood unit identification
number (CBU ID):
269. (Cord blood unit only) Is the CBU ID number also the ICCBBA ISBT 128 number?
1
yes
2
no
270. (Cord blood unit only) Name of cord blood bank providing CBU:
271. Donor’s gender:
1
male
2
female

272. Was the donor ever pregnant?
1
yes
2
no
273. Specify number of pregnancies:
3
unknown
4
not applicable,
cord blood unit

CIBMTR Form 2006 (INF) v1.0 (11–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

unknown

CIBMTR Center Number:

CIBMTR Recipient ID:

274. Donor’s blood type and Rh factor:
1
A positive
2
A negative
3
B positive
4
B negative
5
AB positive
6
AB negative
7
O positive
8
O negative
9
unknown
275. Did this donor have a central line placed?
1
yes
276. Specify the site of the central line placement:
2
no
1
femoral
3
not applicable,
2
subclavian
cord blood unit
3
internal jugular
or marrow product
277. Specify site:
4
other site
278. Donor’s ethnicity:
1
Hispanic or Latino
2
not Hispanic nor Latino
3
unknown
279. Donor’s race: (Mark the group(s) in which the donor is a member. Check all that apply.) A
White
1
2
3
4
5
6
7
8
9
10

Eastern European
Mediterranean
Middle Eastern
North Coast of Africa
North American
Northern European
Western European
White Caribbean
White South or
Central American

Other White

Black or African American
11
African (both parents
born in Africa)
12
African American
13
Black Caribbean
14
Black South or
Central American
American Indian or
Alaska Native
15
Alaskan Native or
Aleut
16
North American
Indian

17

American Indian,

South or Central
America
18
Caribbean Indian
Asian

21

22

23

24

25

19
20

South Asian
Filipino (Pilipino)
Japanese
Korean
Chinese
Vietnamese
Other Southeast
Asian

280. What is the relationship of the donor to the recipient?
1
sibling
2
recipient’s child
3
other relative
281. Specify the relationship of the donor to the recipient:
4
unrelated
1
parent

aunt

uncle
4
cousin
5
other
2
3

relative

282. Specify relationship:

CIBMTR Form 2006 (INF) v1.0 (12–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

Native Hawaiian or Other
Pacific Islander
26
Guamanian
27
Hawaiian
28
Samoan
29
Other Pacific Islander
Decline
30

Donor declines to

31

Donor’s race

provide race
unknown

CIBMTR Center Number:

CIBMTR Recipient ID:

283. Was the donor / product tested for potentially transplantable genetic diseases?
1
yes
Specify disease(s) tested:
2
no
284. 1
yes 2
no Sickle cell anemia
3
unknown
285. 1
yes 2
no Thalassemia
286. 1
yes 2
no Other
287. Specify genetic disease:

The following questions 288–297 apply only to allogeneic non-NMDP donors. If the stem cell product was from an
autologous donor or NMDP donor, or was a cord blood unit, then continue with question 298.
288. Was the donor hospitalized (inpatient) during or after the collection?
1
yes
2
no
289. Did the donor experience any life-threatening complications during or after the collection?
1
yes
290. Specify complications:
2
no
291. Did the donor recieve blood transfusions as a result of the collection?
1
yes
292. Was the blood transfusion product autologous?
2
no
1
yes
293. Specify number of units:
2
no
294. Was the blood transfusion product allogeneic (homologous)?
1
yes
295. Specify number of units:
2
no
296. Did the donor die as a result of the collection?
1
yes
297. Specify cause of death:
2
no
298. (Related donors only) Did the recipient submit a research sample?
1
yes
299. Research sample recipient ID:
2
no
300. (Related donors only) Did the donor submit a research sample?
1
yes
301. Research sample donor ID:
2
no

302. Signed:
Person completing form

Please print name:
Phone number: (
Fax number: (

)
)

E-mail address:
CIBMTR Form 2006 (INF) v1.0 (13–13) July 2007 Draft 04/20/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0 Replaces: F00040 version 3.1 and F00041 version 1.0

CIBMTR Center Number:
CIBMTR Recipient ID:

Confirmation of HLA Typing

Non-NMDP Donor ID: *
Non-NMDP Cord Blood Unit ID: *

Registry Use Only
* See page 5 for additional ID boxes or donor date of birth and gender.
Sequence
Number:

2 0

Today’s Date:
Month

Day

Year

Date of HSCT for which this form is
being completed: 

Date
Received:

HSCT type:

allogeneic,
unrelated

Product type:
marrow

2 0
Month

allogeneic,
related

PBSC

Day

Year

syngeneic
(identical twin)

cord blood
other product,
specify:

This form must be completed for all non-NMDP allogeneic or syngeneic donors or recipients, or non-NMDP cord
blood units. If the donor, recipient, or cord blood unit was secured through the NMDP, then report HLA typing on
the appropriate NMDP forms.
A separate copy of this form should be completed for each non-NMDP donor, recipient, or cord blood unit.
1. Please specify the person for whom this typing is being done:
1
recipient — final typing
2. Was the recipient’s mother used as the donor?
2
recipient’s mother — confirmatory typing
1
yes
2
no

recipient’s father — confirmatory typing

donor — confirmatory typing
5
cord blood unit — confirmatory typing
6
maternal HLA typing
3
4

7

other

3. Was the recipient’s father used as the donor?
1
yes
2
no

4. Specify person and typing:

HLA Typing by DNA Technology
Six sets of boxes are provided for reporting several possible alleles for each allele at a locus. If the laboratory reports more than six
possible alleles, report six of the alleles in the boxes provided and write the remainder of the alleles in the space above or below the
boxes for that locus.
5. Is a copy of the lab report attached?
1
yes
2
no

CIBMTR Form 2005 v1.0 (1–5) July 2007 Draft 04/19/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0

Replaces: n/a

Mail this form to your designated campus
(Milwaukee or Minneapolis). Retain the
original at the transplant center.

CIBMTR Center Number:

CIBMTR Recipient ID:

Class I
Locus

6.

7.

8.

A

B

C

No. of
Alleles
Provided
1

one

2

two

3

not tested

1

one

2

two

3

not tested

1

one

2

two

3

not tested

Allele Designations

First A*

Second A*

First B*

Second B*

First C*

Second C*

Class II
Locus

9. DRB1

No. of
Alleles
Provided
1

one

2

two

3

not tested

Allele Designations

First DRB1*

Second DRB1*

Class II (Optional)
Please provide the optional allele information if it is available from your laboratory.

Locus

10. DRB3

11. DRB4

No. of
Alleles
Provided

one
2
two
3
none
4
not tested
1

one
2
two
3
none
4
not tested
1

Allele Designations

First DRB3*

Second DRB3*

First DRB4*

Second DRB4*

CIBMTR Form 2005 v1.0 (2–5) July 2007 Draft 04/19/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0

Replaces: n/a

CIBMTR Center Number:

CIBMTR Recipient ID:

Class II (Optional)

Locus

12. DRB5

13. DQB1

No. of
Alleles
Provided

one
2
two
3
none
4
not tested
1

one
2
two
1

Allele Designations

First DRB5*

Second DRB5*

First DQB1*

Second DQB1*

14. DPB1

1
2

one

two

First DPB1*

Second DPB1*

15. DQA1

one
2
two
1

First DQA1*

Second DQA1*

16. DPA1

1
2

one

two

First DPA1*

Second DPA1*

CIBMTR Form 2005 v1.0 (3–5) July 2007 Draft 04/19/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0

Replaces: n/a

CIBMTR Center Number:

CIBMTR Recipient ID:

Antigens Defined by Serologic Typing
Use the following lists when reporting HLA-A and B antigens. Report broad antigens only when your laboratory was not able to
confirm typing for a known split antigen.
A Antigens

B Antigens

6. No. of antigens provided:
1
one
2
two

7. Number of antigens provided:
1
one
2
two

Specificity

A1
A2
A203
A210
A3
A9
A10
A11
A19
A23(9)
A24(9)
A2403
A25(10)
A26(10)
A28
A29(19)
A30(19)
A31(19)
A32(19)
A33(19)
A34(10)
A36
A43
A66(10)
A68(28)
A69(28)
A74(19)
A80
AX

Antigen
1st
2nd

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
99

Specificity

Antigen
1st
2nd

Specificity

Antigen
1st
2nd

B5
B7
B703
B8
B12
B13
B14
B15
B16
B17
B18
B21
B22
B27
B2708
B35
B37
B38(16)
B39(16)
B3901
B3902

B40
B4005
B41
B42
B44(12)
B45(12)
B46
B47
B48
B49(21)
B50(21)
B51(5)
B5102
B5103
B52(5)
B53
B54(22)
B55(22)
B56(22)
B57(17)
B58(17)

CIBMTR Form 2005 v1.0 (4–5) July 2007 Draft 04/19/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0

Replaces: n/a

01
02
03
04
05
06
07
08
09
10
11
12
13
14
59
15
16
17
18
19
20

21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41

Specificity

Antigen
1st
2nd

B59
B60(40)
B61(40)
B62(15)
B63(15)
B64(14)
B65(14)
B67
B70
B71(70)
B72(70)
B73
B75(15)
B76(15)
B77(15)
B78
B81
B82
BX

42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
60
99

CIBMTR Center Number:

CIBMTR Recipient ID:

Optional Antigen Reporting
Please provide the following optional antigen information if it is available from your laboratory. This information will be entered into the
NMDP Registry and be available for future patient searches.

Antigens Defined by Serologic Typing
C Antigens

DR Antigens

8. No. of antigens provided:
1
one
2
two
Antigen
1st
2nd

Specificity

Cw1
Cw2
Cw3
Cw4
Cw5
Cw6
Cw7
Cw8
Cw9(w3)
Cw10(w3)
CX

11. No. of antigens provided:
1
one
2
two
Specificity

01
02
03
04
05
06
07
08
09
10
99

DR1
DR103
DR2
DR3
DR4
DR5
DR6
DR7
DR8
DR9
DR10
DR11(5)
DR12(5)
DR13(6)
DR14(6)
DR1403
DR1404
DR15(2)
DR16(2)
DR17(3)
DR18(3)
DRX

Bw Specificity
Specificity

9. Bw4
10. Bw6

Present?
2

yes
3
yes
1

4

DR51 Antigen

no

no

Antigen
1st
2nd

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
81
99

Specificity

12. DR51

DP Antigens

Present?
1
yes 2

16. No. of antigens provided:
1
one
2
two

no

DR52 Antigen
Specificity

13. DR52

1

Present?
2

yes

Specificity

DPw1
DPw2
DPw3
DPw4
DPw5
DPw6
DPX

no

DR53 Antigen
Specificity

14. DR53

1

Present?
2

yes

no

DQ Antigens

Antigen
1st
2nd

01
02
03
04
05
06
99

15. No. of antigens provided:
1
one
2
two
Specificity

DQ1
DQ2
DQ3
DQ4
DQ5(1)
DQ6(1)
DQ7(3)
DQ8(3)
DQ9(3)
DQX

Antigen
1st
2nd

01
02
03
04
05
06
07
08
09
99

17. Signed:
Person completing form

Please print name:
Phone number: (

)

Fax number: (

)

E-mail address:
Continued from page 1
If multiple cord blood units were infused, record each of the non-NMDP cord blood unit identification numbers below:
Non-NMDP Cord Blood Unit ID:
Non-NMDP Cord Blood Unit ID:
If non-NMDP donors were used, record the identification number and/or gender and date of birth for each donor below:
Non-NMDP Donor ID:

Non-NMDP Donor ID:
CIBMTR Form 2005 v1.0 (5–5) July 2007 Draft 04/19/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0

Replaces: n/a

— OR — Donor gender:
1
male
2
female

Donor date of birth:

— OR — Donor gender:
1
male
2
female

Donor date of birth:

Month

Month

Day

Day

Year

Year

CIBMTR Center Number:
CIBMTR Recipient ID:

Infectious Disease Markers

Non-NMDP Donor ID: *
Non-NMDP Cord Blood Unit ID: *

Registry Use Only
* See page 3 for additional ID boxes or donor date of birth and gender.
Sequence
Number:

2 0

Today’s Date:
Month

Day

Year

Date of HSCT for which this form is
being completed: 

Date
Received:

HSCT type:

allogeneic,
unrelated

Product type:
marrow

2 0
Month

allogeneic,
related

Day

Year

syngeneic
(identical twin)

PBSC
cord blood
other product,
specify:

This form must be completed for all non-NMDP allogeneic or syngeneic donors, or non-NMDP cord blood units.
If the donor or cord blood unit was secured through the NMDP, then report IDMs on forms 24 and 50 for allogeneic
donors or through CORD Link for cord blood units.
1. Who is being tested for IDMs?
1
donor IDM (marrow or PBSC)
2
maternal IDM (cord blood)
3
cord blood unit IDM

Infectious Disease Marker (report final test results)

Test Date

Hepatitis B Virus (HBV)

Month

2. HBsAg: (hepatitis B surface antigen)
1
reactive
2
non-reactive
3
testing not performed
4. Anti HBc: (hepatitis B core antibody) (no confirmatory test available)
1
reactive
2
non-reactive
3
testing not performed

Day

Year

3.

2 0

5.

2 0

7.

2 0

9.

2 0

Hepatitis C Virus (HCV)
6. Anti-HCV: (hepatitis C antibody)
1
reactive
2
non-reactive
3
testing not performed
Human T-Lymphotropic Virus
8. Anti-HTLV I / II:
1
reactive
2
non-reactive
3
testing not performed

CIBMTR Form 2004 v1.0 (1–3) January 2007 Draft 04/27/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0

Replaces: n/a

Mail this form to your designated campus
(Milwaukee or Minneapolis). Retain the
original at the transplant center.

CIBMTR Center Number:

CIBMTR Recipient ID:

Infectious Disease Marker (report final test results)

Test Date
Month

Human Immunodeficiency Virus (HIV)
10. HIV-1 p24 antigen:
1
reactive
2
non-reactive
3
not reported
4
not performed; HIV NAT testing performed (skip date)
12. Was FDA licensed NAT testing for HIV-1 / HCV performed?
1
yes
Specify results:
2
no
13. HIV-1
1
positive
2
negative
3
not reported
15. HCV
1
positive
2
negative
17. Anti-HIV 1 and anti-HIV 2*:
(antibodies to Human Immunodeficiency Viruses)

Day

Year

11.

2 0

14.

2 0

16.

2 0

18.

2 0

* Testing for both HIV antibodies is required. This testing may be performed as separate tests or done using a combined assay.

reactive

non-reactive
3
testing not performed
4
not reported
1
2

Syphilis
19. STS:
1
reactive
2
non-reactive
3
testing not performed

20.

2 0

22.

2 0

24.

2 0

Cytomegalovirus (CMV)
21. Anti-CMV: (IgG or Total)
1
reactive
2
non-reactive
3
previously reported reactive, not tested (skip date)
4
testing not performed
West Nile Virus (WNV)
23. WNV-NAT testing:
1
positive
2
negative
3
testing not performed
4
not applicable
25. Other infectious disease marker, specify (e.g., EBV):
1
yes
26. Specify date performed:
2
no
27. Specify test and method:
28. Specify test results:
CIBMTR Form 2004 v1.0 (2–3) January 2007 Draft 04/27/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0

Replaces: n/a

2 0

CIBMTR Center Number:

CIBMTR Recipient ID:

Infectious Disease Marker (report final test results)

Test Date

29. Other infectious disease marker, specify (e.g., EBV):
1
yes
30. Specify date performed:
2
no

Month

Day

Year

2 0

31. Specify test and method:
32. Specify test results:
33. Other infectious disease marker, specify (e.g., EBV):
1
yes
34. Specify date performed:
2
no

2 0

35. Specify test and method:
36. Specify test results:

37. Signed:
Person completing form

Please print name:
Phone number: (

)

Fax number: (

)

E-mail address:

Continued from page 1
If multiple cord blood units were infused, record each of the non-NMDP cord blood unit identification numbers below:
Non-NMDP Cord Blood Unit ID:
Non-NMDP Cord Blood Unit ID:

If non-NMDP donors were used, record the identification number and/or gender and date of birth for each donor below:
Non-NMDP donor ID:
— OR —

Donor gender:
male

female

Donor date of birth:

Donor gender:
male

female

Donor date of birth:

Month

Day

Year

Month

Day

Year

Non-NMDP donor ID:
— OR —

CIBMTR Form 2004 v1.0 (3–3) January 2007 Draft 04/27/2007
Copyright © 2007 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.
For internal use only: Document F00xxx version 1.0

Replaces: n/a