2 Hla

2005: Confirmation of HLA Typing

Registry Use Only
Sequence Number:

Date Received:
Key Fields
For more information on HLA Typing by DNA Technology see the CIBMTR Data Management Manual section Form 2005.

OMB No: 0915-0310
Expiration Date: 7/31/2016
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 is estimated to average 1.0 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 10-29, Rockville,
Maryland, 20857.

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

Product type (check all that apply) ☐ Bone marrow

☐ Allogeneic, related

☐ PBSC
☐ Single cord blood unit
☐ Multiple cord blood units
☐ Other product. Specify:____________________________________________________________________

CIBMTR Form 2005 revision 5 (page 1 of 7). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Donor/Cord Blood Unit Identification

Questions: 1-12

For more information on HLA Typing by DNA technology, see the CIBMTR Data Management Manual section Form 2005.

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. Parental typing (maternal and
paternal) should be submitted for all mismatched related donor transplants (CRF track only), if available. Cord blood maternal typing
should be submitted for all unrelated cord blood transplants (CRF track only), if available.
1.

Specify the person for whom this typing is being done

☐ Recipient — final typing - Go to question 13
☐ Recipient’s biological relative - Go to question 5
☐ Unrelated donor — confirmatory typing - Go to question 2
☐ Cord blood unit — confirmatory typing - Go to question 3
☐ Cord blood unit maternal HLA typing- Go to question 3
2.

Non-NMDP unrelated donor ID: ________________________ (not applicable for related donor)
- Go to question 7

3.

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.

4.

Is the cord blood unit maternal HLA typing available?

5.

Specify recipient’s biological relative and typing

☐ yes - Go to question 7 Also complete form 2005 to report cord blood unit maternal HLA typing
☐ no - Go to question 7

☐ Recipient’s mother – confirmatory typing
☐ Recipient’s father – confirmatory typing
☐ Recipient’s sibling – confirmatory typing
☐ Recipient’s syngeneic (identical) twin– confirmatory typing
☐ Recipient’s fraternal twin– confirmatory typing
☐ Recipient’s child – confirmatory typing
☐ Recipient’s aunt – confirmatory typing
☐ Recipient’s uncle – confirmatory typing
☐ Recipient’s cousin – confirmatory typing
☐ Other biological relative

7.

Date of birth (donor/infant)

☐ Known

☐ Unknown

6.

Specify other biological relative and typing: _________________

8.

Date of birth: __ __ __ __ / __ __ / __ __
YYYY
MM
DD

9.

Age (donor/infant)

☐ Known 10. Age (donor/infant) ___ ___

☐ Unknown
☐ Months (use if less than 1 year old)

☐ years

11. Sex (donor/infant) ☐ male

☐ female

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

CIBMTR Form 2005 revision 5 (page 2 of 7). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ yes

☐ no

CIBMTR Center Number: ___ ___ ___ ___ ___

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

HLA Typing by DNA Technology
13. Was documentation submitted to the CIBMTR? (e.g. lab report)

Questions: 13-35

☐ 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
14. Locus A

☐ Known
☐ Unknown

15. First A* allele designations: _______________________________________________

Second A* allele designations:_____________________________________________

16. Locus B

☐ Known
☐ Unknown

17. First B* allele designations:_______________________________________________

Second B* allele designations: ____________________________________________

18. Locus C

☐ Known
☐ Unknown

19. First C* allele designations:_______________________________________________

Second C* allele designations: ____________________________________________

Class II
20. Locus DRB1

☐ Known
☐ Unknown

21. First DRB1* allele designations: ___________________________________________

Second DRB1* allele designations:_________________________________________

Class II (Optional)
Please provide the optional allele information if it is available from your laboratory.
22. Locus DRB3

☐ Known
☐ Unknown

23. First DRB3* allele designations: ___________________________________________

Second DRB3* allele designations:_________________________________________

24. Locus DRB4

☐ Known
☐ Unknown

25. First DRB4* allele designations:____________________________________________

Second DRB4* allele designations:_________________________________________

26. Locus DRB5

☐ Known
☐ Unknown

27. First DRB5* allele designations: ___________________________________________

Second DRB5* allele designations:_________________________________________

CIBMTR Form 2005 revision 5 (page 3 of 7). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

28. Locus DQB1

☐ Known
☐ Unknown

29. First DQB1* allele designations: ___________________________________________

Second DQB1* allele designations:_________________________________________

30. Locus DPB1

☐ Known
☐ Unknown

31. First DPB1* allele designations:____________________________________________

Second DPB1* allele designations:_________________________________________

32. Locus DQA1

☐ Known
☐ Unknown

33. First DQA1* allele designations:____________________________________________

Second DQA1* allele designations:_________________________________________

34. Locus DPA1

☐ Known
☐ Unknown

35. First DPA1* allele designations:____________________________________________

Second DPA1* allele designations:__________________________________________

Antigens Defined by Serologic Typing

Questions: 36-41

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
36. Number of antigens provided

☐ one
☐ two

37. Specificity – 1st antigen

☐ A1
☐ A2

☐ A203

☐ A210
☐ A3

☐ A9

☐ A10
☐ A11
☐ A19
☐ A23(9)
☐ A24(9)
☐ A2403

38. Specificity – 2nd antigen

☐ A1

☐ A2

☐ A203

☐ A210
☐ A3

☐ A9

CIBMTR Form 2005 revision 5 (page 4 of 7). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ 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

☐ 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

CIBMTR Center Number: ___ ___ ___ ___ ___

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

B Antigens
39. Number of antigens provided

☐ one
☐ two

40. 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)

41. 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

☐ 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

Questions: 42-58

Please provide the following optional antigen information if it is available from your laboratory.
Antigens Defined by Serologic Typing
C Antigens
42. Number of antigens provided
43. Specificity – 1st antigen
☐ one

☐ two

☐ Cw1
☐ Cw2
☐ Cw3

☐ Cw4
☐ Cw5
☐ Cw6

44. Specificity – 2nd antigen

☐ Cw1
☐ Cw2
☐ Cw3

CIBMTR Form 2005 revision 5 (page 5 of 7). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ Cw4
☐ Cw5
☐ Cw6

☐ Cw7
☐ Cw10(W3)
☐ Cw8
☐ CX
☐ Cw9(W3)

☐ Cw7
☐ Cw10(W3)
☐ Cw8
☐ CX
☐ Cw9(W3)

CIBMTR Center Number: ___ ___ ___ ___ ___
Bw Specificity
45. Specificity Bw4 present?

☐ yes

46. Specificity Bw6 present? ☐ yes

DR Antigens
47. Number of antigens provided

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

☐ no
☐ no

☐ one
☐ two

48. Specificity – 1st antigen

☐ DR1
☐ DR103
☐ DR2
☐ DR3
☐ DR4

☐ DR5
☐ DR6
☐ DR7
☐ DR8
☐ DR9

49. Specificity – 2nd antigen

DR51 Specificity

50. Specificity DR51 present? ☐ yes
DR52 Antigen

51. Specificity DR52 present? ☐ yes
DR53 Antigen

52. Specificity DR53 present? ☐ yes

☐ DR1
☐ DR103
☐ DR2
☐ DR3
☐ DR4

☐ DR5
☐ DR6
☐ DR7
☐ DR8
☐ DR9

☐ DR10
☐ DR11(5)
☐ DR12(5)
☐ DR13(6)
☐ DR14(6)

☐ DR1403 ☐ DR18(3)
☐ DR1404 ☐ DRX
☐ DR15(2)
☐ DR16(2)
☐ DR17(3)

☐ DR10
☐ DR11(5)
☐ DR12(5)
☐ DR13(6)
☐ DR14(6)

☐ DR1403 ☐ DR18(3)
☐ DR1404 ☐ DRX
☐ DR15(2)
☐ DR16(2)
☐ DR17(3)

☐ DQ5(1)
☐ DQ6(1)

☐ DQ7(3)
☐ DQ8(3)

☐ DQ9(3)
☐ DQX

☐ DQ5(1)
☐ DQ6(1)

☐ DQ7(3)
☐ DQ8(3)

☐ DQ9(3)
☐ DQX

☐ no
☐ no
☐ no

DQ Antigens
53. Number of antigens provided

☐ one
☐ two

54. Specificity – 1st antigen

☐ DQ1
☐ DQ2

☐ DQ3
☐ DQ4

55. Specificity – 2nd antigen

☐ DQ1
☐ DQ2

☐ DQ3
☐ DQ4

DP Antigens
56. Number of antigens provided

☐ one
☐ two

57. Specificity – 1st antigen

☐ DPw1
☐ DPw2

☐ DPw3
☐ DPw4

58. Specificity – 2nd antigen

☐ DPw1
☐ DPw2

CIBMTR Form 2005 revision 5 (page 6 of 7). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ DPw3
☐ DPw4

☐ DPw5
☐ DPX
☐ DPw6
☐ DPw5
☐ DPw6

☐ DPX

CIBMTR Center Number: ___ ___ ___ ___ ___

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

First Name:_____________________________________________________
Last Name:_____________________________________________________
E-mail address:__________________________________________________
Date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD

CIBMTR Form 2005 revision 5 (page 7 of 7). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.