Form 1 Form_2006_R4+. Hematopoietic Cellular Transplant (HCT) I

2006: Hematopoietic Cellular Transplant (HCT)
Infusion

Registry Use Only
Sequence Number:

Date Received:

Key Fields
OMB No: 0915-0310
Expiration Date: 1/31/2017
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 only one) ☐ Autologous

☐ Allogeneic, unrelated

Product type (check only one) ☐ Bone marrow

☐ Allogeneic, related

☐ PBSC
☐ Single cord blood unit
☐ Other product. Specify:________________________________________________________________________

CIBMTR Form 2006 revision 4 (page 1 of 30). 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
1.

Questions: 1-15

Specify donor

☐ Autologous - Go to question 16
☐ Autologous cord blood unit - Go to question 5
☐ NMDP unrelated cord blood unit - Go to question 2
☐ NMDP unrelated donor - Go to question 3
☐ Related donor - Go to question 10
☐ Related cord blood unit - Go to question 5
☐ Non-NMDP unrelated donor - Go to question 4
☐ Non-NMDP unrelated cord blood unit - Go to question 5
2.

NMDP cord blood unit ID: ________________________ - Go to question 15

3.

NMDP donor ID: ________________________ - Go to question 15

4.

Non-NMDP unrelated donor ID: ________________________ (not applicable for related donor)
- Go to question 8

5.

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

6.

Is the CBU ID also the ISBT DIN number?

☐ yes
☐ no

8.

Registry or UCB Bank ID

7.

Specify the ISBT DIN number:____________________________

☐ (A) Austrian Bone Marrow Donors
☐ (ACB) Austrian Cord Blood Registry
☐ (ACCB) StemCyte, Inc.
☐ (AE) Emirates Bone Marrow Donor Registry
☐ (AM) Armenian Bone Marrow Donor Registry Charitable Trust
☐ (AOCB) University of Colorado Cord Blood Bank
☐ (AR) Argentine CPH Donors Registry
☐ (ARCB) BANCEL - Argentina Cord Blood Bank
☐ (AUCB) Australian Cord Blood Registry
☐ (AUS) Australian/New Zealand Bone Marrow Donor Registry
☐ (B) Marrow Donor Program Belgium
☐ (BCB) Belgium Cord Blood Registry
☐ (BG) Bulgarian Bone Marrow Donor Registry
☐ (BR) INCA/REDOMO
☐ (BSCB) British Bone Marrow Registry - Cord Blood
☐ (CB) Cord Blood Registry
☐ (CH) Swiss BloodStem Cells - Adult Donors
☐ (CHCB) Swiss Blood Stem Cells - Cord Blood
☐ (CKCB) Celgene Cord Blood Bank
☐ (CN) China Marrow Donor Program (CMDP)
☐ (CNCB) Shan Dong Cord Blood Bank
☐ (CND) Canadian Blood Services Bone Marrow Donor Registry
☐ (CS2) Czech National Marrow Donor Registry

CIBMTR Form 2006 revision 4 (page 2 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ (CSCR) Czech Stem Cells Registry
☐ (CY) Cyprus Paraskevaidio Bone Marrow Donor Registry
☐ (CY2) The Cyprus Bone Marrow Donor Registry
☐ (D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors
☐ (DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood
☐ (DK) The Danish Bone Marrow Donor Registry
☐ (DK2) Bone Marrow Donors Copenhagen (BMDC)
☐ (DUCB) German Branch of the European Cord Blood Bank
☐ (E) REDMO
☐ (ECB) Spanish Cord Blood Registry
☐ (F) France Greffe de Moelle - Adult Donors
☐ (FCB) France Greffe de Moelle - Cord Blood
☐ (FI) Finnish Bone Marrow Donor Registry
☐ (FICB) Finnish Cord Blood Registry
☐ (GB) The Anthony Nolan Trust
☐ (GB3) Welsh Bone Marrow Donor Registry
☐ (GB4) British Bone Marrow Registry
☐ (GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece
☐ (GRCB) Michigan Community Blood Centers Cord Blood Bank
☐ (H) Hungarian Bone Marrow Donor Registry
☐ (HEM) Hema-Quebec
☐ (HK) Hong Kong Bone Marrow Donor Registry
☐ (HR) Croatian Bone Marrow Donor Registry
☐ (I) Italian Bone Marrow Donor Registry
☐ (I3CB) Sheba Medical Centre Cord Blood Registry
☐ (ICB) Italian Cord Blood Bank Network
☐ (IL) Hadassah BMDR
☐ (IL2) Ezer Mizion Bone Marrow Donor Registry
☐ (IL3) Sheba Medical Center Donor Registry
☐ (ILCB) Isreal Cord Blood Bank
☐ (IN) Asian Indian Donor Marrow Registry
☐ (IN2) Dept. of Transfusion Medicine
☐ (IRL) The Irish Unrelated Bone Marrow Panel
☐ (JP) Japan Marrow Donor Program
☐ (KR) Korea Marrow Donor Program
☐ (LT) Lithuanian National Bone Marrow Donor Registry
☐ (LVCB) Leuven Cord Blood Bank
☐ (MACB) Victoria Angel Registry of Hope
☐ (MX) Mexican Bone Marrow Donor Registry
☐ (N) The Norwegian Bone Marrow Donor Registry
☐ (NL) Europdonor Foundation- Adult Donors
☐ (NLCB) Europdonor Foundation - Cord Blood
☐ (NYCB) National Cord Blood Program, New York Blood Center
☐ (P) Portuguese Bone Marrow Donors Registry

CIBMTR Form 2006 revision 4 (page 3 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ (PL) National Polish Bone Marrow Registry
☐ (PL2) Unrelated Bone Marrow Donor Registry -Adult Donors
☐ (PL3) Against Leukemia Foundation Marrow Donor Registry
☐ (PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry
☐ (PL5) Polish Central Bone Marrow Donor Registry - Adult Donors
☐ (PMCB) Elie Katz Umbilical Cord Blood Program
☐ (R) Russian Bone Marrow Donor Registry
☐ (R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells
☐ (S) Tobias Registry of Swedish Bone Marrow Donors
☐ (SG) Singapore Bone Marrow Donor Programme (BMDP)
☐ (SK) Slovak National Bone Marrow Donor Registry
☐ (SKCB) Eurocord Slovakia/Slovak Pacental Stem Cell Registry
☐ (SLCBB) St Louis Cord Blood Bank
☐ (SLO) Slovenia Donor
☐ (SM) San Marino Bone Marrow Donor Registry
☐ (T1CB) TRAN - Cord Blood
☐ “(TACB) StemCyte, Inc. Taiwan”
☐ “(TECB) Healthbanks Biotech, Co., Ltd “
☐ (TH) Thai Stem Cell Donor Registry (TSCDR)
☐ (TOCB) Tokyo Cord Blood Bank
☐ (TPCB) BIONET/BabyBanks
☐ (TRAN) TRAN - Adult Donors
☐ (TRIS) Bone Marrow Bank of Istanbul Medical Faculty
☐ (TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors
☐ (TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood
☐ (U1CB) National Marrow Donor Program - Cord Blood
☐ (USA1) National Marrow Donor Program - Adult Donors
☐ (USA2) America Bone Marrow Donor Registry
☐ (UY) SINDOME
☐ (VIAC) Viacord
☐ (W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood
☐ (WACB) Unrelated Bone Marrow Donor Registry - Cord Blood
☐ (ZA) South African Bone Marrow Registry
☐ (OTH) Other Registry

CIBMTR Form 2006 revision 4 (page 4 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

9.

Specify other Registry or UCB Bank:______________________

CIBMTR Center Number: ___ ___ ___ ___ ___

10. Date of birth (donor/infant)

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

☐ Known

11. Date of birth: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

☐ Unknown

12. Age (donor/infant)

☐ Known 13. Age (dongor/infant) ___ ___
☐ Unknown
☐ Months (use only if less than 1 year old) ☐ years

14. Sex (donor/infant) ☐ male

☐ female

15. Was the product derived from an NMDP adult donor, NMDP cord blood unit, or non-NMDP cord blood unit?

☐ yes - Go to question 43
☐ no - Go to question 16

Pre-Collection Therapy

Questions: 16-27

16. Did the donor receive therapy, prior to any stem cell harvest, to enhance the product collection for this HCT?

☐ yes
☐ no

17. Growth and mobilizing factor(s)

☐ yes
☐ no

18. G-CSF
19. Pegylated G-CSF

20. GM-CSF

21. Plerixafor (Mozobil)

22. Other growth or mobilizing factor

☐ yes

☐ yes
☐ yes
☐ yes
☐ yes

☐ no
☐ no
☐ no
☐ no

23. Specify other growth or mobilizing factor:

☐ no
___________________________________

24. Systemic therapy (chemotherapy) (autologous only)

☐ yes

25. Anti-CD20 (rituximab, Rituxan) (autologous only)

☐ yes
☐ no

27. Specify other therapy:___________________________________

☐ no

26. Other therapy

CIBMTR Form 2006 revision 4 (page 5 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Product Collection

Questions: 28-42

If more than one type of HCT product is infused, each product type must be analyzed and reported separately.
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 appicable), even if the collections are performed on different days.

28. Date of first collection for this mobilization: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
29. Was more than one collection required for this HCT?

☐ yes
☐ no

Complete a separate CIBMTR form 2006 – HCT Infustion for each subsequent collection
that was not part of this mobilization.
30. Specify the number of subsequent days of collection in this episode: ___

31. Were anticoagulants added to the product during collection?

☐ yes
☐ no

Specify anticoagulant(s):

☐ yes
☐ yes
☐ yes

32. Acid citrate dextrose (ACD)
33. Citrate phosphate dextrose (CPD)
34. Heparin

☐ no
☐ no
☐ no

35. Other anticoagulant

☐ yes
☐ no

36. Specify other anticoagulant:______________________________

37. Were anticoagulants added to the product before freezing?

☐ yes
☐ no

Specify anticoagulant(s):
38. Acid citrate dextrose (ACD)
39. Citrate phosphate dextrose (CPD)
40. Heparin

☐ yes
☐ yes
☐ yes

☐ no
☐ no
☐ no

41. Other anticoagulant

☐ yes
☐ no

42. Specify other anticoagulant:______________________________

Product Transport and Receipt

Questions: 43-56

43. Was this product collected off-site and shipped to your facility?

☐ yes
☐ no

44. Date of receipt of product at your facility: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
45. Time of receipt of product (24-hour clock):

___ ___ - ___ ___ ☐ standard time ☐ daylight savings time
HH
MM

46. Specify the shipping environment of the product(s)

☐ Frozen gel pack (refrigerator temperature)
☐ Frozen cord blood unit(s)
☐ Room temperature per transplant center request

CIBMTR Form 2006 revision 4 (page 6 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ Other shipping environment

47. Specify other shipping
environment:

___________________________

48. Was there any indication that the environment within the shipper was outside the

expected temperature range for this product at any time during shipment? (Cord blood

units only)

☐ yes

49

Were the secondary containers (e.g., insulated shipping containers and unit cassette)
intact when they arrived at your center? (Cord blood units only)

☐ yes

☐ no
☐ no

50. Was the cord blood unit stored at your center prior to thawing?

☐ yes
☐ no

51. Specify the storage method used for the cord blood unit

☐ Electric freezer

☐ Liquid nitrogen

☐ Vapor phase

52. Temperature during storage

☐ < -150° C

☐ ≥ -150° C to < -135° C
☐ ≥ -135° C to < -80° C
☐ ≥ -80° C

53. Date storage started: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
Report the total number of cells (not cells per kilogram) prior to cryopreservation:
(Information provided for the unit by the cord blood bank).
54. Total nucleated cells: ___ ___ ___ ● ___ ___ x 10 ___ ___ (Includes nucleated red and

nucleated white cells) (Cord blood units only)
55. CD34+ cells (cord blood units only)

☐ Done
☐ Not done

56. Total number of CD34+ cells:

___ ___ ___ ● ___ ___ x 10 ___ ___

Product Processing/Manipulation

Questions: 57-108

57. Was a fresh product received (e.g. not frozen)? (NMDP products only)

☐ Yes

☐ No
☐ not applicable, cord blood unit

58. Was the entire fresh product cryopreserved at your facility prior to infusion? (NMDP

products only)

☐ yes

☐ no

59. Was the product thawed from a cryopreserved state prior to infusion?

☐ yes
☐ no

60. Was the entire product thawed?

☐ yes
☐ no

61. Was only a compartment of the bag thawed? (Cord blood units

only) ☐ yes

CIBMTR Form 2006 revision 4 (page 7 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ no

CIBMTR Center Number: ___ ___ ___ ___ ___

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

62. Were there multiple product bags?

☐ yes
☐ no

63. Specify number of bags thawed: ___ ___

64. Date thawing process initiated: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
65. Time at initiation of thaw (24-hour clock):

___ ___ - ___ ___ ☐ standard time ☐ daylight savings time
HH
MM

66. Time product ready for infusion or expansion (24-hour clock):

___ ___ - ___ ___ ☐ standard time ☐ daylight savings time
HH
MM

67. Was the primary container (e.g., cord blood unit bag) intact upon thawing?

☐ yes

☐ no

68. What method was used to thaw the product?

☐ Waterbath
☐ Electric warmer
☐ Other method

69.

Specify other method:__________________

70. Did any adverse events, incidents, or product complaints occur while preparing or

thawing the product?

☐ yes

☐ no

71. Was the product manipulated prior to infusion?

☐ yes
☐ no

72. Specify portion manipulated ☐ entire product
Specify all methods used to manipulate the product:
73. Washed
74. Diluted
75. Buffy coat enriched (buffy coat preparation)
76. B-cell reduced
77. CD8 reduced
78. Plasma reduced (removal)
79. RBC reduced
80. Cultured (ex-vivo expansion)
81. Genetic manipulation (gene transfer/transduction)
82. PUVA treated
83. CD34 enriched (CD34+ selection)
84. CD133 enriched
85. Monocyte enriched
86. Mononuclear cells enriched

CIBMTR Form 2006 revision 4 (page 8 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ portion of product
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes

☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no

CIBMTR Center Number: ___ ___ ___ ___ ___

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

87. T-cell depletion

☐ yes
☐ no

Specify method:
88. Antibody affinity column

☐ yes - Report the antibodies used for T-cell depletion at

question 96

☐ no

89. Antibody coated plates

☐ yes - Report the antibodies used for T-cell depletion at

question 96
☐ no

90. Antibody coated plates and soybean lectin

☐ yes - Report the antibodies used for T-cell depletion at

question 96
☐ no

91. Antibody + toxin

☐ yes - Report the antibodies used for T-cell depletion at

question 96
☐ no

92.

Immunomagnetic beads

☐ yes - Report the antibodies used for T-cell depletion at

question 96
☐ no

93. CD34 affinity column plus
sheep red blood cell rosetting

☐ yes

☐ no

94. Other cell manipulation

☐ yes
☐ no

95. Specify other cell manipulation:___________________________

96. Were antibodies used during product manipulation?

☐ yes
☐ no

Specify antibodies:
97. Anti CD2

98. Anti CD3

99. Anti CD4

100. Anti CD5

101. Anti CD6

102. Anti CD7

103. Anti CD8

104. Anti CD19

105. a/ß antibody

106. Anti CD52 (Campath)

107. Other antibody

CIBMTR Form 2006 revision 4 (page 9 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ yes
☐ no

☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes
☐ yes

☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no
☐ no

108. Specify other antibody:_________________

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Autologous Products Only

Questions: 109-157

The following section refers to autologous products only, including autologous cord blood; if this is not an autologous HCT, continue with
the Product Analysis section at question 158.
109. Were tumor cells detected in the recipient or autologous product prior to HCT?

☐ yes
☐ no

Specify tumor cell detection method used and site(s) of tumor cells:
110. Routine histopathology

☐ yes
☐ no

Specify site(s):
111. Circulating blood cells

☐ Yes

☐ No
☐ No

☐ Not done
☐ Not done

113. Collected cells (before purging)

☐ Yes

☐ No

☐ Not done

☐ Yes
☐ Yes

☐ No
☐ No

☐ Not done
☐ Not done

☐ Yes

☐ No

☐ Not done

112. Bone marrow (in the interval between
☐ Yes

last systemic therapy and collection)

114. Polymerase chain reaction (PCR)

☐ yes
☐ no

Specify site(s):
115. Circulating blood cells

116. Bone marrow (in the interval between

last systemic therapy and collection)

117. Collected cells (before purging)

118. Other molecular technique

☐ yes
☐ no

119. Specify method:___________________________________________________
Specify site(s):

☐ Yes

☐ No
☐ No

☐ Not done
☐ Not done

☐ Yes

☐ No

☐ Not done

☐ Yes
☐ Yes

☐ No
☐ No

☐ Not done
☐ Not done

☐ Yes

☐ No

☐ Not done

128. Circulating blood cells

☐ Yes

☐ No
☐ No

☐ Not done
☐ Not done

130. Collected cells (before purging)

☐ Yes

☐ No

☐ Not done

120. Circulating blood cells

121. Bone marrow (in the interval between
☐ Yes

last systemic therapy and collection)

122. Collected cells (before purging)

123. Immunohistochemistry

☐ yes
☐ no

Specify site(s):
124. Circulating blood cells

125. Bone marrow (in the interval between

last systemic therapy and collection)

126. Collected cells (before purging)

127. Cell culture technique

☐ yes
☐ no

Specify site(s):

129. Bone marrow (in the interval between
☐ Yes

last systemic therapy and collection)

131. Other technique

☐ yes
☐ no

132. Specify:___________________________________________________________
Specify site(s):
133. Circulating blood cells

☐ Yes
☐ Yes

☐ No
☐ No

☐ Not done
☐ Not done

☐ Yes

☐ No

☐ Not done

134. Bone marrow (in the interval between

last systemic therapy and collection)

135. Collected cells (before purging)

CIBMTR Form 2006 revision 4 (page 10 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

136. Was the product treated to remove malignant cells (purged)?

☐ yes
☐ no

Specify method(s) used:
137. Monoclonal antibody

☐ yes
☐ no

138. Specify monoclonal antibody:_____________________________

☐ yes
☐ yes

139. 4-hydroperoxycyclophosphamide (4HC)
140. Mafosfamide

☐ no
☐ no

141. Other drug

☐ yes
☐ no

142. Specify other drug:_____________________________________

☐ yes
☐ yes

143. Elutriation
144. Immunomagnetic column

☐ no
☐ no

145. Toxin

☐ yes
☐ no

146. Specify toxin:__________________________________________

147. CD34 selection (other than preparation of mononuclear fraction)

☐ yes
☐ no

148. Specify method:_______________________________________

149. Other method

☐ yes
☐ no

150. Specify:______________________________________________

Specify if tumor cells were detected in the graft after purging by each method used:
151. Routine histopathology
152. Polymerase chain reaction (PCR)
153. Other molecular technique
154. Immunohistochemistry
155. Cell culture technique

☐ Yes
☐ Yes
☐ Yes
☐ Yes
☐ Yes

☐ No
☐ No
☐ No
☐ No
☐ No

☐ Not done
☐ Not done
☐ Not done
☐ Not done
☐ Not done

156. Other

☐ Yes
☐ No
☐ Not done

157. Specify:______________________________________________

Product Analysis (All Products)

Questions: 158-195

158. Specify the timepoint in the product preparation phase that the product was analyzed

☐ Product arrival

☐ Pre-cryopreservation

☐ Post-thaw

159. Date of product analysis: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
160. Total volume of product plus additives: ___ ___ ___ ___ ___ ● ___ mL

CIBMTR Form 2006 revision 4 (page 11 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ At infusion

CIBMTR Center Number: ___ ___ ___ ___ ___

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

In this section, report the total number of cells (not cells per kilogram) not corrected for viability
161. Total nucleated cells (TNC) (Includes nucleated red and nucleated white cells)

☐ Done
☐ Not done

162. Total nucleated cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

163. Nucleated white blood cells

☐ Done
☐ Not done

164. Total number of nucleated white blood cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

165. Mononuclear cells

☐ Done
☐ Not done

166. Total number of mononuclear cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

167. Nucleated red blood cells

☐ Done
☐ Not done

168. Total number of nucleated red blood cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

169. CD34+ cells

☐ Done
☐ Not done

170. Total number of CD34+ cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

171. CD3+ cells

☐ Done
☐ Not done

172. Total number of CD3+ cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

173. CD3+CD4+ cells

☐ Done
☐ Not done

174. Total number of CD3+CD4+ cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

175. CD3+CD8+ cells

☐ Done
☐ Not done

176. Total number of CD3+CD8+ cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

177. Viability of cells

☐ Done
☐ Not done

178. Viability of cells: ___ ___ ___ %
179. Method of testing cell viability

☐ 7-AAD
☐ Propidium iodide
☐ Trypan blue
☐ Other method

180. Specify other method: _________________

181. Were the colony-forming units (CFU) assessed after thawing? (Cord blood units only)

☐ yes
☐ no

182. Was there growth?

☐ yes

☐ no

183. Total CFU-GM

☐ Done
☐ Not done

184. Total CFU-GM: ___ ___ ___ ___ ● ___ x 10 ___ ___

185. Total BFU-E

☐ Done
☐ Not done

186. Total BFU-E: ___ ___ ___ ___ ● ___ x 10 ___ ___

CIBMTR Form 2006 revision 4 (page 12 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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

☐ yes
☐ no

188. Specify results ☐ Positive

☐ Negative

☐ Unknown

Specify organism(s):

189. ☐ 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 non-diptheria 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 Leptorichia 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

CIBMTR Form 2006 revision 4 (page 13 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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
☐ 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

CIBMTR Form 2006 revision 4 (page 14 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 240 Zygomycetes, NOS
☐ 241 Mucormycosis
☐ 242 Rhizopus
☐ 250 Yeast, NOS
☐ 259 Other fungus, specify
☐ 260 Pneumocystis (PCP/PJP)
☐ 503 Suspected fungal infection

190. ☐ 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 non-diptheria 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 Leptorichia buccalis
☐ 149 Leuconostoc(all species)
☐ 104 Listeria
☐ 150 Methylobacterium
☐ 151 Micrococcus, NOS

CIBMTR Form 2006 revision 4 (page 15 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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
☐ 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

CIBMTR Form 2006 revision 4 (page 16 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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

191. ☐ 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 non-diptheria 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

CIBMTR Form 2006 revision 4 (page 17 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 148 Leptorichia 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
☐ 200 Candida, NOS
☐ 201 Candida albicans
☐ 206 Candida guillermondi
☐ 202 Candida krusei
☐ 207 Candida lusitaniae
☐ 203 Candida parapsilosis
☐ 204 Candida tropicalis

CIBMTR Form 2006 revision 4 (page 18 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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

192. ☐ 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 non-diptheria 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)

CIBMTR Form 2006 revision 4 (page 19 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 145 Helicobacter pylori
☐ 146 Klebsiella
☐ 147 Lactobacillus(bulgaricus, acidophilus, other species)
☐ 102 Legionella
☐ 103 Leptospira
☐ 148 Leptorichia 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
☐ 200 Candida, NOS
☐ 201 Candida albicans

CIBMTR Form 2006 revision 4 (page 20 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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

193. ☐ 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 non-diptheria species)
☐ 101 Coxiella
☐ 134 Enterobacter
☐ 177 Enterococcus, vancomycin resistant(VRE)
☐ 135 Enterococcus(all species)

CIBMTR Form 2006 revision 4 (page 21 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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 Leptorichia 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

CIBMTR Form 2006 revision 4 (page 22 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 198 Other bacteria, specify
☐ 501 Suspected atypical bacterial infection
☐ 502 Suspected bacterial infection
☐ 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

194. ☐ 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

CIBMTR Form 2006 revision 4 (page 23 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 133 Corynebacterium (all non-diptheria 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 Leptorichia 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

CIBMTR Form 2006 revision 4 (page 24 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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 - Go to question 195
☐ 501 Suspected atypical bacterial infection
☐ 502 Suspected bacterial infection
☐ 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 - Go to question 195
☐ 210 Aspergillus, NOS
☐ 211 Aspergillus flavus
☐ 212 Aspergillus fumigatus
☐ 213 Aspergillus niger
☐ 219 Other Aspergillus, specify - Go to question 195
☐ 220 Cryptococcus species
☐ 230 Fusarium species
☐ 261 Histoplasmosis
☐ 240 Zygomycetes, NOS
☐ 241 Mucormycosis
☐ 242 Rhizopus
☐ 250 Yeast, NOS
☐ 259 Other fungus, specify - Go to question 195
☐ 260 Pneumocystis (PCP/PJP)
☐ 503 Suspected fungal infection
195. Specify organism: ______________________

Copy questions 158 - 195 if needed for Product Analysis

CIBMTR Form 2006 revision 4 (page 25 of 30). 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: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Product Infusion

Questions: 196-249

196. Date of this product infusion: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
197. Was more than one product infused? (e.g., marrow and PBSC, PBSC and cord blood, two different cords, etc.)

☐ yes
☐ no

198. Was the product infusion described on this insert intended to produce hematopoietic
engraftment?
☐ yes

☐ no

199. Date infusion started: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
200. Time product infusion initiated (24-hour clock): ___ ___ - ___ ___

HH
MM

☐ standard time

☐ daylight savings time

201. Date infusion stopped: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
202. Time product infusion completed (24-hour clock): ___ ___ - ___ ___ ☐ standard time

HH
MM

☐ daylight savings time

203. Total volume of product plus additives intended for infusion: ___ ___ ___ ___ ___ ● ___ mL
204. Was the entire volume of product infused?

☐ yes
☐ no

205. Specify what happened to the reserved portion

☐ discarded
☐ cryopreserved for future use
☐ other fate
206. Specify other fate:_________________________________

207. Specify the route of product infusion

☐ intravenous
☐ intramedullary
☐ intraperitoneal
☐ other route of infusion

208. Specify other route of infusion: ____________________________________________

The following questions refer to all stem cell products except for autologous marrow and autologous PBSC products. If this HCT used an
autologous marrow or autologous PBSC product, continue with the signature lines.
209. Were there any adverse events or incidents associated with the stem cell infusion?

☐ yes
☐ no

Specify the following adverse event(s):
210. Brachycardia

☐ yes
211.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

212. Chest tightness/pain

☐ yes
213.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

214. Chills at time of infusion

☐ yes
215.
☐ no

CIBMTR Form 2006 revision 4 (page 26 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

CIBMTR Center Number: ___ ___ ___ ___ ___

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

216. Fever ≤ 103° F within 24 hours of infusion

☐ yes
217.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

218. Fever > 103° F within 24 hours of infusion

☐ yes
219.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

220. Gross hemoglobinuria

☐ yes
221.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

222. Headache

☐ yes
223.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

224. Hives

☐ yes
225.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

226. Hypertension

☐ yes

227. In the Medical Director’s judgment, was the adverse event a

☐ no
228. Hypotension

direct result of the infusion?

In the Medical Director’s judgment, was the adverse event a

☐ yes
229.
☐ no

direct result of the infusion?

☐ yes
☐ yes

☐ no
☐ no

230. Hypoxia requiring oxygen (O2) support

☐ yes
231.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

232. Nausea

☐ yes
233.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

234. Rigors, mild

☐ yes
235.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

236. Rigors, severe

☐ yes
237.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

238. Shortness of breath (SOB)

☐ yes
239.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

240. Tachycardia

☐ yes
241.
☐ no

CIBMTR Form 2006 revision 4 (page 27 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

CIBMTR Center Number: ___ ___ ___ ___ ___

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

242. Vomiting

☐ yes
243.
☐ no

In the Medical Director’s judgment, was the adverse event a
direct result of the infusion?

☐ yes

☐ no

244. Other expected AE

☐ yes
☐ no

245. Specify other expected AE:_______________________________
246. In the Medical Director’s judgment, was the adverse event a

direct result of the infusion?

☐ yes

☐ no

247. Other unexpected AE

☐ yes
☐ no

248. Specify other unexpected AE:_____________________________
249. In the Medical Director’s judgment, was the adverse event a

direct result of the infusion?

Donor/Infant Demographic Information

☐ yes

☐ no

Questions: 250-285

The Donor Demographic Information section (questions 250-270) is to be completed for all non-NMDP allogeneneic donors. If the stem
cell product was from an NMDP donor or an autologous donor, continue with the signature lines.
250. Was the donor ever pregnant?

☐ Yes
☐ No
☐ Unknown
☐ Not applicable (male donor or cord

251. Number of pregnancies

☐ Known
☐ Unknown

252. Specify number of pregnancies: ___ ___

blood unit)

253. Specify blood type
254. Specify Rh factor

☐ A

☐ B

☐ Positive

☐ AB

☐O

☐ Negative

255. Did this donor have a central line placed?

☐ Yes
☐ No
☐ Not applicable (cord blood unit or

marrow product)

256. Specify the site of the central line placement

258. Ethnicity (donor)

☐ Hispanic or Latino

☐ femoral
☐ subclavian
☐ internal jugular
☐ Other site

☐ Not Hispanic or Latino

CIBMTR Form 2006 revision 4 (page 28 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

257. Specify other site:_________________________________

☐ Not applicable (not a resident of the USA)

☐ Unknown

CIBMTR Center Number: ___ ___ ___ ___ ___

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

259. Race (donor)

☐ White
260. Race detail (donor)
☐ Black or African American

☐ Eastern European

☐ Asian

☐ Mediterranean

☐ American Indian or Alaska Native

☐ Middle Eastern

☐ Native Hawaiian or Other Pacific

☐ North Coast of Africa
Islander

☐ North American

☐ Not reported

☐ Northern European

☐ Unknown

☐ Western European

☐ White Caribbean

☐ White South or Central American

☐ Other White

☐ African (both parents born in Africa)

☐ African American

☐ Black Caribbean

☐ Black South or Central American

☐ Alaskan Native or Aleut

☐ North American Indian
☐ American Indian, South or

Central America

☐ Caribbean Indian
☐ South Asian
☐ Filipino (Pilipino)
☐ Japanese
☐ Korean
☐ Chinese
☐ Vietnamese
☐ Other Southeast Asian
☐ Guamanian
☐ Hawaiian
☐ Samoan
☐ Other Pacific Islander

Copy questions 259 - 260 if needed for Race

261. What is the biological relationship of the donor to the patient?

☐ Sibling
☐ Half-sibling
☐ Syngeneic (identical) twin
☐ Fraternal twin
☐ Recipient’s child
☐ Other biological relative
☐ Unrelated

262. Specify the biological relationship of the donor to the recipient

☐ Mother
☐ Father
☐ Maternal aunt
☐ Maternal uncle
☐ Maternal cousin
☐ Paternal aunt
☐ Paternal uncle
☐ Paternal cousin
☐ Other biological relative

263. Specify:____________________________

264. Was the donor/product tested for potentially transplantable genetic diseases?

☐ yes
☐ no
☐ Unknown

Specify disease(s) tested:
265. Sickle cell anemia

☐ yes
266. Specify results
☐ no
☐ Positive ☐ Carrier of the trait

☐ Negative

267. Thalassemia

☐ yes
268. Specify results
☐ no
☐ Positive ☐ Carrier of the trait

CIBMTR Form 2006 revision 4 (page 29 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.

☐ Negative

CIBMTR Center Number: ___ ___ ___ ___ ___

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

269. Other disease

☐ yes
☐ no

270. Specify other disease:______________________________
271. Specify results

☐ Positive

☐ Carrier of the trait

☐ Negative

The following questions (272–285) apply only to allogeneic related donors. If the stem cell product was from an autologous donor, NonNMDP unrelated donor, NMDP donor, or was a cord blood unit, then continue with the signature lines.
272. Was the donor hospitalized (inpatient) during or after the collection? ☐ yes

☐ no

273. Did the donor experience any life-threatening complications during or after the collection?

☐ yes
☐ no

274. Specify:_______________________________________________________________

275. Did the donor receive blood transfusions as a result of the collection?

☐ yes
☐ no

276. Was the blood transfusion product autologous?

☐ yes
☐ no

277. Specify number of units: ___ ___

278. Was the blood transfusion product allogeneic (homologous)?

☐ yes
☐ no

279. Specify number of units: ___ ___

280. Did the donor die as a result of the collection?

☐ yes
☐ no

281. Specify cause of death: __________________________________________________

282. Did the recipient submit a research sample to the NMDP/CIBMTR repository? (Related donors only)

☐ yes
☐ no

283. Research sample recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

284. Did the donor submit a research sample to the NMDP/CIBMTR repository? (Related donors only)

☐ yes
☐ no

285. Research sample donor ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

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

CIBMTR Form 2006 revision 4 (page 30 of 30). Last Updated October, 2013.
Copyright (c) 2013 National Marrow Donor Program and
The Medical College of Wisconsin, Inc. All rights reserved.