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

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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 HLA Typing Form 2005 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 only one)

 Allogeneic, unrelated

 Allogeneic, related

Product type: (check all that apply)

 Bone marrow

 PBSC

 Single cord blood unit

 Other product

Specify:

This form must be completed for all non-NMDP allogeneic or syngeneic donors, or non-NMDP cord blood units.

Donor / Cord Blood Unit Identification

1. Specify non-NMDP donor:

 Related donor – Go to question 4

 Non-NMDP unrelated donor – Go to question 2

 Non-NMDP cord blood unit (include related and autologous CBUs) – Go to question 3

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

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - Go to question 4

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

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

4. Date of birth (donor / infant):

 Known – Go to question 5

 Unknown – Go to question 6

5. Date of birth (donor / infant): ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 8

6. Age (donor / infant):

 Known – Go to question 7

 Unknown – Go to question 8

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

 Years

8. Sex (donor / infant):

 Male

 Female

9. Who is being tested for IDMs?

 Donor IDM (bone marrow or PBSC)

 Maternal IDM (cord blood)

 Cord blood unit IDM

Infectious Disease Marker (report final test results)

Hepatitis B Virus (HBV)

10. HBsAg: (hepatitis B surface antigen)

 Reactive – Go to question 11

 Non-reactive – Go to question 11

 Not done – Go to question 12

11. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

12. Anti HBc: (hepatitis B core antibody)

 Reactive – Go to question 13

 Non-reactive – Go to question 13

 Not done – Go to question 14

13. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Hepatitis C Virus (HCV)

14. Anti-HCV: (hepatitis C antibody)

 Reactive – Go to question 15

 Non-reactive – Go to question 15

 Not done – Go to question 16

15. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Human T-Lymphotropic Virus

16. Anti-HTLV I / II:

 Reactive – Go to question 17

 Non-reactive – Go to question 17

 Not done – Go to question 18

17. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Human Immunodeficiency Virus (HIV)

18. HIV-1 p24 antigen:

 Reactive – Go to question 19

 Non-reactive – Go to question 19

 Not done – Go to question 20

 Not reported – Go to question 20

19. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

20. Was FDA licensed NAT testing for HIV-1 / HCV performed?

 Yes – Go to questions 21

 No – Go to question 25

Specify results:

21. HIV-1

 Positive – Go to question 22

 Negative – Go to question 22

 Not reported – Go to question 23

22. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

23. HCV

 Positive

 Negative

24. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

25. Anti-HIV 1 and anti-HIV 2*: (antibodies to Human Immunodeficiency Viruses)

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

 Reactive – Go to question 26

 Non-reactive – Go to question 26

 Not done – Go to question 27

 Not reported – Go to question 27

26. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Syphilis

27. STS:

 Reactive – Go to question 28

 Non-reactive – Go to question 28

 Not done – Go to question 29

28. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Cytomegalovirus (CMV)

29. Anti-CMV: (IgG or Total)

 Reactive – Go to question 30

 Non-reactive – Go to question 30

 Not done – Go to question 31

30. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

West Nile Virus (WNV)

31. WNV-NAT testing:

 Positive – Go to question 32

 Negative – Go to question 32

 Not done – Go to question 33

 Not applicable – Go to question 33

32. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Chagas

33. Chagas testing

• Positive – Go to question 34

• Negative – Go to question 34

• Not done – Go to question 35

34. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Herpes simplex virus (HSV)

35. Anti-HSV (Herpes simplex virus antibody)

• Positive – Go to question 36

• Negative – Go to question 36

• Not done – Go to question 37

36. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Epstein–Barr virus (EBV)

37. Anti-EBV (Epstein–Barr virus antibody)

• Positive – Go to question 38

• Negative – Go to question 38

• Inconclusive – Go to question 38

• Not done – Go to question 39

38. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Varicella zoster virus (VZV)

39. Anti-VZV (Varicella zoster virus antibody)

• Positive – Go to question 40

• Negative – Go to question 40

• Not done – Go to question 41

40. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Toxoplasmosis

41. Toxoplasmosis

• Positive – Go to question 42

• Negative – Go to question 42

• Not done – Go to question 43

42. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

Other Infectious Disease Marker

43. Other infectious disease marker, specify:

 Yes – Go to question 44

 No – Go to signature line

44. Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

45. Specify test and method:

46. Specify test results:

Copy questions 44–46 to report multiple other infectious disease markers

First Name:

Last Name:

E-mail address:

Date: ___ ___ ___ ___ - ___ ___ - ___ ___

YYYY MM DD

CIBMTR Form 2004 IDM revision 4 (page 9 of 9) June 2009 FINAL FORM 12/11/2012<

Copyright © 2009 National Marrow Donor Program and

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

Internal use: Document number F00479 revision 2 Replaces: F00479 version 1.0 July 2007