Form 2 HLA

Stem Cell Therapeutic Outcomes Database

2-FINAL 2005-Product Form (HLA) r5

Stem Cell Therapeutic Outcomes Database (Product Form)

OMB: 0915-0310

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CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___


R

OMB No: 0915-0310

Expiration Date: 12/31/2013


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 0915-0310. Public reporting burden for this collection of information, in combination with the IDM Form 2004 and HCT Infusion Form 2006, 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.

Expiration date: 12/31/2013

egistry Use Only

Sequence Number:









Date Received:





CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Date of HCT for which this form is being completed: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD


HCT type: (check all that apply)

Autologous

Allogeneic, unrelated

Allogeneic, related

Product type: (check all that apply)

Bone marrow

PBSC

Single cord blood unit

Multiple cord blood units

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.




Donor / Cord Blood Unit Identification

A separate copy of this form should be completed for each non-NMDP donor, recipient, or cord blood unit.

  1. Specify the person for whom this typing is being done:

Recipient — final typing – Go to question 13

Recipient’s biological mother — confirmatory typing – Go to question 7

Recipient’s biological father — confirmatory typing – Go to question 7

Other biological relative – Go to question 5

Unrelated donor — confirmatory typing – Go to question 2

Cord blood unit — confirmatory typing – Go to question 3

Maternal HLA typing – Go to question 3

  1. Non-NMDP unrelated donor ID: (not applicable for related donor)

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - Go to question 7

  1. Non-NMDP cord blood unit ID: (include related and autologous CBUs)

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - If reporting Maternal HLA typing, go to question 12. If reporting Cord blood unit – confirmatory typing, go to question 4.

  1. Was the maternal HLA typing considered in the selection of the cord blood unit?

Yes – Go to question 7

No – Go to question 7

  1. Specify recipient’s other biological relative and typing:

Recipient’s sibling – confirmatory typing – Go to question 7

Recipient’s half sibling– confirmatory typing – Go to question 7

Recipient’s syngeneic (identical) twin– confirmatory typing – Go to question 7

Recipient’s fraternal twin– confirmatory typing – Go to question 7

Recipient’s maternal aunt – confirmatory typing – Go to question 7

Recipient’s maternal uncle – confirmatory typing – Go to question 7

Recipient’s maternal cousin – confirmatory typing – Go to question 7

Recipient’s paternal aunt – confirmatory typing – Go to question 7

Recipient’s paternal uncle – confirmatory typing – Go to question 7

Recipient’s paternal cousin – confirmatory typing – Go to question 7

Other biological relative – Go to question 6

  1. Specify other biological relative and typing: ________________________________________

  2. Date of birth: (donor / infant)

Known – Go to question 8

Unknown – Go to question 9

  1. Date of birth: (donor / infant) ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 11

  2. Age: (donor / infant)

Known – Go to question 10

Unknown – Go to question 11

  1. Age: (donor / infant) ___ ___ Months (use only if less than 1 year old)

Years

  1. Sex: (donor / infant)

Male

Female

  1. Was the person for whom this typing is being done used as the donor?

Yes

No



HLA Typing by DNA Technology

  1. Was documentation submitted to the CIBMTR? (e.g. lab report)

Yes

No



HLA Alleles Defined by DNA Technology (e.g., Sequence Specific Oligonucleotide Probe (SSOP) typing, Sequence Specific Primer (SSP) typing or Sequence Based (SBT) typing.)

DNA technology can be used to type for a single allele, combinations of alleles (allele strings) or a “generic” allele designation which is similar to a serologic typing result. For this reason, the number of digits, as well as the number of alleles, for reporting will vary.

Laboratories may use “ / ” , “ – ” or a combination of numbers and letters on the typing report as a shorthand notation for the results. Transcribe the information onto the form as directly as possible. The letters are called allele codes, and will be 1 or more characters in length which represent a combination of possible alleles at a locus. The same allele combination may be reported several different ways (e.g., DRB1*01:01 or 01:02, DRB1*01:01/01:02, DRB1*01:01/02, or DRB1*01:AB).

There will be two alleles reported for each locus, unless the individual is presumed homozygous (i.e., carries two copies of the same allele) at a locus. Transcribe the first allele designation in the first box, and the second allele designation in the second box. If the person is homozygous, leave the second box blank.

Class I

  1. Locus A

 Known – Go to question 15

 Unknown – Go to question 16

  1. First A* allele designations







Second A* allele designations







  1. Locus B

 Known – Go to question 17

 Unknown – Go to question 18

  1. First B* allele designations







Second B* allele designations







  1. Locus C

 Known – Go to question 19

 Unknown – Go to question 20

  1. First C* allele designations







Second C* allele designations








Class II

  1. Locus DRB1

 Known – Go to question 21

 Unknown – Go to question 22

  1. First DRB1* allele designations







Second DRB1* allele designations








Class II (Optional)

Please provide the optional allele information if it is available from your laboratory.

  1. Locus DRB3

 Known – Go to question 23

 Unknown – Go to question 24

  1. First DRB3* allele designations







Second DRB3* allele designations







  1. Locus DRB4

 Known – Go to question 25

 Unknown – Go to question 26

  1. First DRB4* allele designations







Second DRB4* allele designations







  1. Locus DRB5

 Known – Go to question 27

 Unknown – Go to question 28

  1. First DRB5* allele designations







Second DRB5* allele designations









  1. Locus DQB1

 Known – Go to question 29

 Unknown – Go to question 30

  1. First DQB1* allele designations







Second DQB1* allele designations







  1. Locus DPB1

 Known – Go to question 31

 Unknown – Go to question 32

  1. First DPB1* allele designations







Second DPB1* allele designations







  1. Locus DQA1

 Known – Go to question 33

 Unknown – Go to question 34

  1. First DQA1* allele designations







Second DQA1* allele designations







  1. Locus DPA1

 Known – Go to question 35

 Unknown – Go to question 36

  1. First DPA1* allele designations







Second DPA1* allele designations









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.

Instructions for the use of the “X” Antigen Specificity for Typing By Serology

Each HLA locus has a serologically defined “X” antigen specificity: AX, BX, CX, DRX, DPX, and DQX. At this time an “X” specificity is defined as “unknown but known to be different from the other antigen at that locus.” This is different from a blank specificity, which is defined as “unknown but assumed to be the same as the other antigen at that locus.” When comparisons between recipient and donor antigens involve an “X” or “blank” specificity, the “X” or “blank” is assumed to be homozygous for the antigen reported at the locus. In other words, the search algorithm treats typings containing “blank” or “X” antigens in the same manner as known homozygous typings.

A Antigens

  1. Number of antigens provided:

One – Go to question 37, then continue with question 39

Two – Go to questions 37-38

  1. Specificity – 1st antigen

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

  1. Specificity – 2nd antigen

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

B Antigens

  1. Number of antigens provided:

One – Go to question 40, then continue with question 42

Two – Go to questions 40-41

  1. Specificity – 1st antigen

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)

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

  1. Specificity – 2nd antigen

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)

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



Optional Antigen Reporting

Please provide the following optional antigen information if it is available from your laboratory.

Antigens Defined by Serologic Typing

C Antigens

  1. Number of antigens provided:

One – Go to question 43, then continue with question 45

Two – Go to questions 43-44

  1. Specificity – 1st antigen

Cw1

Cw2

Cw3

Cw4

Cw5

Cw6

Cw7

Cw8

Cw9(w3)

Cw10(w3)

CX

  1. Specificity – 2nd antigen

Cw1

Cw2

Cw3

Cw4

Cw5

Cw6

Cw7

Cw8

Cw9(w3)

Cw10(w3)

CX

Bw Specificity

  1. Specificity Bw4 present?

Yes

No

  1. Specificity Bw6 present?

Yes

No

DR Antigens

  1. Number of antigens provided:

One – Go to question 48, then continue with question 50

Two – Go to questions 48-49

  1. Specificity – 1st antigen

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

  1. Specificity – 2nd antigen

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

DR51 Antigen

  1. Specificity DR51 present?

Yes

No

DR52 Antigen

  1. Specificity DR52 present?

Yes

No

DR53 Antigen

  1. Specificity DR53 present?

Yes

No

DQ Antigens

  1. Number of antigens provided:

One – Go to question 54, then continue with question 56

Two – Go to questions 54-55

  1. Specificity – 1st antigen

DQ1

DQ2

DQ3

DQ4

DQ5(1)

DQ6(1)

DQ7(3)

DQ8(3)

DQ9(3)

DQX

  1. Specificity – 2nd antigen

DQ1

DQ2

DQ3

DQ4

DQ5(1)

DQ6(1)

DQ7(3)

DQ8(3)

DQ9(3)

DQX

DP Antigens

  1. Number of antigens provided:

One – Go to question 57, then continue with signature line

Two – Go to questions 57-58

  1. Specificity – 1st antigen

DPw1

DPw2

DPw3

DPw4

DPw5

DPw6

DPX

  1. Specificity – 2nd antigen

DPw1

DPw2

DPw3

DPw4

DPw5

DPw6

DPX





First Name:

Person completing form

Last Name:

E-mail address:

Date: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD



CIBMTR Form 2005 HLA revision 5 (page 20 of 20) April 2010 DRAFT 12/11/2012<

Copyright © 2010 National Marrow Donor Program and

The Medical College of Wisconsin, Inc. All rights reserved.

Internal use: Document number F00480 revision 3 Replaces: F00480 revision 2

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