Form 3 ProductForm-Infusion, HLA, Infectious Disease Marker

Hematopoietic Cellular Transplant (HCT) Infusion

OMB No: 0915-0310
Expiration Date: 1/31/2020

Registry Use Only
Sequence Number:

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 HLA Typing Form 2005, 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: 1/31/2020

Date Received:

CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event Date: __ __ __ __ / __ __ / __ __

YYY
MM
DD
HCT type (check only one)

☐ Autologous

Product type (check only one)

NMDP Product:

☐ Yes

☐ Allogeneic, unrelated

☐ Allogeneic, related

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

☐ No

Product Identifiers:
NMDP cord blood unit ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
NMDP donor ID: __ __ __ __ - __ __ __ __ - __
Non-NMDP unrelated donor ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Non-NMDP cord blood unit ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
GRID (optional): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
ISBT DIN: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Registry or UCB Bank ID: __ __ __ __
Donor DOB: __ __ __ __ / __ __ / __ __

YYYY MM DD
Donor Age: __ __ ☐ Months (use only if less than 1 year old)
Donor Sex: ☐ Male

☐ Years

☐ Female

CIBMTR Form 2006 revision 5 (page 1 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

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 applicable), even if the collections are performed on different days.
Pre-Collection Therapy
1.

Did the donor receive growth and mobilizing factors, prior to any stem cell harvest, to enhance the product collection for this HCT? Allogeneic
donors only

☐ Yes
☐ No

2.

Specify growth and mobilizing factor(s) (Check all that apply)

☐ G-CSF (filgrastim, Neupogen)
☐ Pegylated G-CSF (pegfilgrastim, Neulasta)
☐ Plerixafor (Mozobil)
☐ Other growth or mobilizing factor(s)

3.

Specify other growth or mobilizing factor(s):

_______________________________________

Product Collection
4. Date of first collection for this mobilization: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
5.

Were anticoagulants or other agents added to the product between collection and infusion?

☐ Yes
☐ No

6.

Specify anticoagulant(s): (check all that apply)

☐ Acid citrate dextrose (ACD, ACD-A)
☐ Citrate phosphate dextrose (CPD, CPD-A)
☐ Ethylenediaminetetraacetic acid (EDTA)
☐ Heparin
☐ Other
7.
Specify other anticoagulant:

_______________________________________

Product Transport and Receipt
8.

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

☐ Yes
☐ No

9.
Date of receipt of product at your facility: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
10.

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

___ ___ : ___ ___ ☐ standard time ☐ daylight savings time
Hour
Minute

CIBMTR Form 2006 revision 5 (page 2 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___
11.

CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify the shipping environment of the product(s)

☐ Room temperature
☐ Cooled (refrigerator temperature, not frozen)
☐ Frozen (cryopreserved)
☐ Other shipping environment
12.

13.

Specify other shipping environment:
____________________________
– If product is cord blood, go to
question 13; all other products _
go to question 22

Was there any indication that the environment within the shipper was outside the
expected temperature range for this product at any time during shipment?

☐ Yes

14

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

☐ Yes

☐ No
☐ No

15. Was the cord blood unit stored at your center prior to thawing? (Cord blood units only)

☐ Yes
☐ No

16.

Specify the storage method used for the cord blood unit

17.

Temperature during storage

☐ Electric freezer

☐ Liquid nitrogen

☐ Vapor phase

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

18. 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).
19.

Total nucleated cells: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___ (Includes nucleated red
and nucleated white cells) (Cord blood units only)

20.

CD34+ cells (cord blood units only)

☐ Done

☐ Not done

21. Total number of CD34+ cells:

___ ___ ___ ___ ● ___ ___ x 10 ___ ___

CIBMTR Form 2006 revision 5 (page 3 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Product Processing / Manipulation
22. Was the product thawed from a cryopreserved state prior to infusion?

☐ Yes
☐ No

23. Was the entire product thawed?

☐ Yes

☐ No
24.

Specify the percent of the product that was thawed? (Cord blood units only)

☐ 80%
☐ 20%
☐ Other percent

25. Specify other percent: __ __ %

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

YYYY
MM
DD
27. Time at initiation of thaw (24-hour clock): ___ ___ : ___ ___ ☐ standard time ☐ daylight savings time

Hour
Minute
28. Time of thaw completion (24-hour clock): ___ ___ : ___ ___ ☐ standard time ☐ daylight savings time

Hour
Minute
29. What method was used to thaw the product?

☐ Waterbath
☐ Electric warmer
☐ Other method

30. Specify other method:________________________________

31. Did any incidents, or product complaints occur while preparing or thawing the product?
32. Was the product processed prior to infusion?

☐ Yes
☐ No

33.

Specify processing: (check all that apply)

☐ Buffy coat enriched (buffy coat preparation)
☐ Diluted
☐ Plasma reduced
☐ RBC reduced
☐ Washed

34. Was the product manipulated prior to infusion?

☐ Yes
☐ No

35.

Specify manipulations performed: (check all that apply)

☐ Antibodies - Go to question 36
☐ Ex-vivo expansion - Go to question 36
☐ Genetic manipulation (gene transfer / transduction) - Go to question 36
☐ CD34 enriched (CD34+ selection) - Go to question 36
☐ Ex-vivo T-cell depletion - Go to question 38
☐ Other manipulation - Go to question 40

CIBMTR Form 2006 revision 5 (page 4 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

☐ yes

☐ no

CIBMTR Center Number: ___ ___ ___ ___ ___

36.

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

Specify antibodies used: (check all that apply)

☐ Anti CD3
☐ Anti CD4
☐ Anti CD8
☐ Anti CD19
☐ Anti CD34
☐ Anti CD45RA
☐ α/β Antibody
☐ Anti CD52
☐ Other antibody

38.

Specify T-cell depletion method:

☐ Antibody affinity column
☐ Immunomagnetic beads
☐ Other method

40.

37. Specify other antibody:_________________

39. Specify other method:__________________

Specify other cell manipulation:__________________________________________

Product Analysis (All Products)
41. Specify the timepoint in the product preparation phase that the product was analyzed:

☐ Product arrival (cord blood only)

☐ At infusion (final quantity infused)

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

YYYY
MM
DD
43. Total volume of product plus additives : ___ ___ ___ ___ ___ ● ___mL

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

☐ Done
☐ Not done

45.

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

46.

Viability of cells

☐ Done
☐ Not done
☐ Unknown

47.

Viability of cells: ___ ___ ___ %

48.

Method of testing cell viability:

☐ Flow cytometry based
☐ Trypan blue
☐ Other method

49. Specify other method:__________________

CIBMTR Form 2006 revision 5 (page 5 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

50. Nucleated white blood cells

☐ Done
☐ Not done

51.

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

53.

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

52. Mononuclear cells

☐ Done
☐ Not done

54. Nucleated red blood cells

☐ Done
☐ Not done

55.

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

57.

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

58.

Viability of cells

56. CD34+ cells

☐ Done
☐ Not done

☐ Done
☐ Not done
☐ Unknown

59.

Viability of cells: ___ ___ ___ %

60.

Method of testing cell viability:

☐ Flow cytometry based
☐ Trypan blue
☐ Other method

61. Specify other method:__________________

62. CD3+ cells

☐ Done
☐ Not done

63.

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

64.

Viability of cells

☐ Done
☐ Not done
☐ Unknown

65.

Viability of cells: ___ ___ ___ %

66.

Method of testing cell viability:

☐ Flow cytometry based
☐ Trypan blue
☐ Other method

67. Specify other method:__________________

CIBMTR Form 2006 revision 5 (page 6 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

68. CD3+CD4+ cells

☐ Done
☐ Not done

69.

Total number of CD3+CD4+: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

70.

Viability of cells

☐ Done
☐ Not done
☐ Unknown

71.

Viability of cells: ___ ___ ___ %

72.

Method of testing cell viability:

☐ Flow cytometry based
☐ Trypan blue
☐ Other method

73. Specify other method:__________________

74. CD3+CD8+ cells

☐ Done
☐ Not done

75.

Total number of CD3+CD8+: ___ ___ ___ ___ ● ___ ___ x 10 ___ ___

76.

Viability of cells

☐ Done
☐ Not done
☐ Unknown

77.

Viability of cells: ___ ___ ___ %

78.

Method of testing cell viability:

☐ Flow cytometry based
☐ Trypan blue
☐ Other method

79. Specify other method:__________________

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

☐ Yes
☐ No

81.

Was there growth?

82.

Total CFU-GM

☐ Done
☐ Not done
84.

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

Total CFU-GEMM

☐ Done
☐ Not done
86.

83.

☐ Yes

85.

Total CFU-GEMM: ___ ___ ___ ___ ● ___ x 10 ___ ___

87.

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

Total BFU-E

☐ Done
☐ Not done

CIBMTR Form 2006 revision 5 (page 7 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

☐ No

CIBMTR Center Number: ___ ___ ___ ___ ___

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

88. Were any positive cultures (for bacterial or fungal infections) obtained from the product at the transplant center? (complete for all cell products)

☐ Yes
☐ No
☐ Pending
☐ Unknown

Specify organism code(s):
89.

___ ___ ___

90. ___ ___ ___

91. ___ ___ ___

92. ___ ___ ___

93.

Specify organism: ____________________________________________________

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

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)

CIBMTR Form 2006 revision 5 (page 8 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

☐ 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

CIBMTR Form 2006 revision 5 (page 9 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

☐ 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
Copy questions 41-93 to report multiple instances of Product Analysis

Product Infusion
94. Date of this product infusion: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
95. Was the entire volume of received product infused?

☐ Yes
☐ No

96. Specify what happened to the reserved portion:

☐ Discarded
☐ Cryopreserved for future use
☐ Other fate

97. Specify other fate:________________________________________

98. Time product infusion initiated (24-hour clock): ___ ___ : ___ ___ ☐ standard time ☐ daylight savings time

Hour
Minute
99. Date infusion stopped: __ __ __ __ / __ __ / __ __

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

Hour
Minute

CIBMTR Form 2006 revision 5 (page 10 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

101. Specify the route of product infusion:

☐ Intravenous
☐ Intramedullary (Intraosseous)
☐ Other route of infusion

102. Specify other route of infusion:____________________________________________

The following questions are applicable to cord blood units only. Non-NMDP allogeneic products continue with question 144. Autologous
and NMDP products continue with the signature lines.
103. Were there any adverse events or incidents associated with the stem cell infusion?

☐ Yes
☐ No

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

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

106. Chest tightness / pain

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

108. Chills at time of infusion

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

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

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

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

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

114. Gross hemoglobinuria

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

CIBMTR Form 2006 revision 5 (page 11 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

116. Headache

☐ Yes
☐ No

1174. In the Medical Director’s judgment, was the adverse event a

direct result of the infusion?

☐ Yes

☐ No

118. Hives

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

120. Hypertension

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

122. Hypotension

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

124. Hypoxia requiring oxygen (O2) support

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

126. Nausea

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

128. Rigors, mild

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

130. Rigors, severe

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

CIBMTR Form 2006 revision 5 (page 12 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

132. Shortness of breath (SOB)

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

134. Tachycardia

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

136. Vomiting

☐ Yes
☐ No

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

direct result of the infusion?

☐ Yes

☐ No

138. Other expected AE

☐ Yes
☐ No

139. Specify other expected AE:____________________________
140. In the Medical Director’s judgment, was the adverse event a

direct result of the infusion?

☐ Yes

☐ No

141. Other unexpected AE

☐ Yes
☐ No

142. Specify other unexpected AE:__________________________
143. In the Medical Director’s judgment, was the adverse event a

direct result of the infusion?

☐ Yes

☐ No

CIBMTR Form 2006 revision 5 (page 13 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Donor / Infant Demographic Information
This Donor Demographic Information section (questions 144-170) is to be completed for all non-NMDP allogeneic donors. If the stem cell
product was from an NMDP donor or an autologous donor, continue with the signature lines.
144. Was the donor ever pregnant?

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

145. Number of pregnancies

☐ Known
☐ Unknown

146. Specify number of pregnancies: ___ ___

blood unit)

☐ Yes

☐ No

☐ Unknown

☐ Not applicable (not a resident of the USA)

☐ Unknown

147. Did this donor have a central line placed?
148. Ethnicity (donor)

☐ Hispanic or Latino

☐ Not Hispanic or Latino

149. Race (donor) (check all that apply)

☐ White
☐ Black or African American
☐ Asian
☐ American Indian or Alaska Native
☐ Native Hawaiian or Other Pacific Islander
☐ Not reported
☐ Unknown

- Go to Question 151

150. Race detail (donor) (check all that apply)

☐ Eastern European
☐ Mediterranean
☐ Middle Eastern
☐ North Coast of Africa
☐ North American
☐ Northern European
☐ 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
☐ Other Black
☐ Alaskan Native or Aleut
☐ North American Indian
☐ American Indian, South or Central America
☐ Caribbean Indian
☐ South Asian
☐ Filipino (Pilipino)
☐ Japanese

CIBMTR Form 2006 revision 5 (page 14 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

☐ Korean
☐ Chinese
☐ Vietnamese
☐ Other Southeast Asian
☐ Guamanian
☐ Hawaiian
☐ Samoan
☐ Other Pacific Islander
☐ Unknown

151. Was the donor a carrier for potentially transplantable genetic diseases?

☐ Yes
☐ No

152. Specify potentially transplantable genetic disease:

☐ Sickle cell anemia
☐ Thalassemia
☐ Other hemoglobinopathy
☐ Other disease

153. Specify other disease:____________________

154. Was the donor / product tested for other transferable genetic or clonal abnormalities?

☐ Yes - Go to question 155
☐ No - If this is a related donor, go to question 160; all other donor types go to signature line
☐ Unknown - If this is a related donor, go to question 160; all other donor types go to signature line
155. Clonal hematopoiesis of indeterminate potential (CHIP):

☐ Yes
☐ No

156. What was the method of testing used?____________________

157. Monoclonal B-cell lymphocytosis

☐ Yes

☐ No

158. Other transferable genetic or clonal abnormality

☐ Yes
☐ No

159. Specify other transferable genetic or clonal abnormality:

__________________________________________________

The following questions (160–167) 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.
160. Was the donor hospitalized (inpatient) during or after the collection?

☐ yes

☐ no

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

☐ Yes
☐ No

162. Specify:_______________________________________________________________

CIBMTR Form 2006 revision 5 (page 15 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

163. Did the allogeneic donor give one or more autologous transfusion units?

☐ Yes
☐ No

164. Date of collection: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

165. Number of units: __ __

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

☐ Autologous transfusions

☐ Allogenic transfusions
☐ No

167. Specify number of autologous units: ___ ___

168. Specify number of allogenic units: ___ ___

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

☐ Yes
☐ No - Go to signature line

170. Specify cause of death: __________________________________________________

First Name (person completing form):_________________________________
Last Name:______________________________________________________
E-mail address:__________________________________________________
Date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD

CIBMTR Form 2006 revision 5 (page 16 of 16). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

Confirmation of HLA Typing

OMB No: 0915-0310
Expiration Date: 1/31/2020

Registry Use Only
Sequence Number:

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: 1/31/2020

Date Received:

CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event date: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
Product Identifiers:
NMDP cord blood unit ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Non-NMDP unrelated donor ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Non-NMDP cord blood unit ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
GRID (optional): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
ISBT DIN: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Registry or UCB Bank ID: __ __ __ __
Donor DOB: __ __ __ __ / __ __ / __ __

YYYY MM DD
Donor Age: __ __ ☐ Months (use only if less than 1 year old)
Donor Sex:

☐ Male

☐

☐ Years

Female

CIBMTR Form 2005 revision 7 (page 1 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Donor/Cord Blood Unit Identification
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 ☐ Donor

HLA Typing by DNA Technology
2.

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
3.

5.

7.

Locus A

☐ Known
☐ Unknown

4.

First A* allele designations

Second A* allele designations

6.

First B* allele designations

Second B* allele designations

8.

First C* allele designations

Second C* allele designations

Locus B

☐ Known
☐ Unknown

Locus C

☐ Known
☐ Unknown

CIBMTR Form 2005 revision 7 (page 2 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Class II
9.

Locus DRB1

☐ Known
☐ Unknown

10. First DRB1* allele designations

Second DRB1* allele designations

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

☐ Known
☐ Unknown

12. First DRB3* allele designations

Second DRB3* allele designations

13. Locus DRB4

☐ Known
☐ Unknown

14. First DRB4* allele designations

Second DRB4* allele designations

15. Locus DRB5

☐ Known
☐ Unknown

16. First DRB5* allele designations

Second DRB5* allele designations

17. Locus DQB1

☐ Known
☐ Unknown

18. First DQB1* allele designations

Second DQB1* allele designations

CIBMTR Form 2005 revision 7 (page 3 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

19. Locus DPB1

☐ Known
☐ Unknown

20. First DPB1* allele designations

Second DPB1* allele designations

21. Locus DQA1

☐ Known
☐ Unknown

22. First DQA1* allele designations

Second DQA1* allele designations

23. Locus DPA1

☐ Known
☐ Unknown

24. 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
25. Number of antigens provided:

☐ One - Go to question 26, then continue with question 28
☐ Two - Go to questions 26-27
26. Specificity – 1st antigen

☐ A1

☐ A2

☐ A203

☐ A210

☐ A3

CIBMTR Form 2005 revision 7 (page 4 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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

27. 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)

CIBMTR Form 2005 revision 7 (page 5 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ A31(19)
☐ A32(19)
☐ A33(19)
☐ A34(10)
☐ A36
☐ A43
☐ A66(10)
☐ A68(28)
☐ A69(28)
☐ A74(19)
☐ A80
☐ AX

B Antigens
28. Number of antigens provided:

☐ One - Go to question 29, then continue with question 31
☐ Two - Go to questions 29-30
29.

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

CIBMTR Form 2005 revision 7 (page 6 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

30.

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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
Specificity – 2nd antigen

☐ B5
☐ B7
☐ B703
☐ B8
☐ B12

CIBMTR Form 2005 revision 7 (page 7 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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)

CIBMTR Form 2005 revision 7 (page 8 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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
31. Number of antigens provided:

☐ One - Go to question 32, then continue with question 34
☐ Two - Go to questions 32-33
32. Specificity – 1st antigen

☐ Cw1

☐ Cw2

☐ Cw3

☐ Cw4

☐ Cw5

☐ Cw6

☐ Cw7

☐ Cw8

☐ Cw9(w3)

☐ Cw10(w3)

☐ CX
33.

Specificity – 2nd antigen

☐ Cw1

☐ Cw2

☐ Cw3

☐ Cw4

☐ Cw5

☐ Cw6

CIBMTR Form 2005 revision 7 (page 9 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ Cw7
☐ Cw8
☐ Cw9(w3)
☐ Cw10(w3)
☐ CX

Bw Specificity
34. Specificity Bw4 present?
35. Specificity Bw6 present?
DR Antigens
36. Number of antigens provided:

☐ One - Go to question 37, then continue with question 39
☐ Two - Go to questions 37-38
37. 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

38.

Specificity – 2nd antigen

☐ DR1
☐ DR103
☐ DR2

CIBMTR Form 2005 revision 7 (page 10 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

☐ Yes
☐ Yes

☐ No
☐ No

CIBMTR Center Number: ___ ___ ___ ___ ___

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ 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
39. Specificity DR51 present?

☐ Yes

☐ No

☐ Yes

☐ No

☐ Yes

☐ No

DR52 Antigen
40. Specificity DR52 present?
DR53 Antigen
41. Specificity DR53 present?
DQ Antigens
42. Number of antigens provided:

☐ One - Go to question 43, then continue with question 45
☐ Two - Go to questions 43-44
43. Specificity – 1st antigen

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

CIBMTR Form 2005 revision 7 (page 11 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

44.

CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

☐ DQ9(3)
☐ DQX
Specificity – 2nd antigen

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

DP Antigens
45. Number of antigens provided:

☐ One - Go to question 46, then continue with signature line
☐ Two - Go to questions 46-47
46.

Specificity – 1st antigen

☐ DPw1
☐ DPw2
☐ DPw3
☐ DPw4
☐ DPw5
☐ DPw6
☐ DPX

47. 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 revision 7 (page 12 of 12). Form released November, 2018. Last Updated April, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

Infectious Disease Markers

OMB No: 0915-0310
Expiration Date: 1/31/2020

Registry Use Only
Sequence Number:

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: 1/31/2020

Date Received:

CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event date: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
HCT type (check all that apply):

☐ Allogeneic, unrelated

☐ Allogeneic, related

Product type (check all that apply):

☐ Bone marrow

☐ PBSC

☐ Single cord blood unit

☐ Multiple cord blood units ☐ Other product. Specify:___________________

Product Identifiers:
NMDP cord blood unit ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Non-NMDP unrelated donor ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Non-NMDP cord blood unit ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
GRID (optional): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
ISBT DIN: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Registry or UCB Bank ID: __ __ __ __
Donor DOB: __ __ __ __ / __ __ / __ __

YYYY MM DD
Donor Age: __ __ ☐ Months (use only if less than 1 year old)
Donor Sex: ☐ Male

☐ Years

☐ Female

CIBMTR Form 2004 revision 5 (page 1 of 4). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

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.

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)
Hepatitus B Virus (HBV)
2.

HBsAg: (hepatitus B surface antigen)

☐ Reactive
☐ Non-reactive
☐ Not done

4.

Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

5.

Date sample collected: __ __ __ __ / __ __ / __ __
YYYY
MM
DD

Anti HBc: (hepatitus B core antibody)

☐ Reactive
☐ Non-reactive
☐ Not done

6.

3.

Was FDA licensed NAAT testing for HBV performed?

☐ Positive
☐ Negative
☐ Not done

7.

Date sample collected: __ __ __ __ / __ __ / __ __
YYYY
MM
DD

Hepatitis C Virus (HCV)
8.

Anti-HCV: (hepatitis C antibody)

☐ Reactive
☐ Non-reactive
☐ Not done

9. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

☐ Yes
☐ No
☐ Not done

11. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

10. Was FDA licensed NAAT testing for HCV performed?

Human Immunodeficiency Virus (HIV)
12. HIV-1 p24 antigen:

☐ Reactive
☐ Non-reactive
☐ Not done

☐ Not reported

13. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

CIBMTR Form 2004 revision 5 (page 2 of 4). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

14. Was FDA licensed NAAT testing for HIV-1 performed?

☐ Yes
☐ No
☐ Not done

15. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

16. 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
☐ Non-reactive
☐ Not done

☐ Not reported

17. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

Chagas
18. Chagas testing

☐ Positive
☐ Negative
☐ Not done

19. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

Herpes simplex virus (HSV)
20. Anti-HSV (Herpes simplex virus antibody)

☐ Positive
☐ Negative

☐ Not done

21. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

Epstein-Barr virus (EBV)
22. Anti-EBV (Epstein-Barr virus antibody)

☐ Positive
☐ Negative

☐ Inconclusive

☐ Not done

23. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

Varicella zoster virus (VZV)
24. Anti-VZV (Varicella zoster virus antibody)

☐ Positive
☐ Negative

☐ Not done

25. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD

CIBMTR Form 2004 revision 5 (page 3 of 4). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Other Infectious Disease Marker
26. Other infectious disease marker, specify:

☐ Yes
☐ No

27. Date sample collected: __ __ __ __ / __ __ / __ __

YYYY
MM
DD
28. Specify test and method:__________________________________________________
29. Specify test results: _____________________________________________________
Copy questions 27 - 29 to report multiple other infectious disease markers

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

CIBMTR Form 2004 revision 5 (page 4 of 4). Form released November, 2018. Last Updated January, 2019.
Copyright (c) 2018 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.