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pdfPre-Transplant Essential Data
OMB No: 0915-0310
Expiration Date: 10/31/2022
CIBMTR Use Only
Sequence Number:
Public Burden Statement: The purpose of the data collection is to fulfill the legislative mandate to
establish and maintain a standardized database of allogeneic marrow and cord blood transplants
performed in the United States or using a donor from the United States. The data collected also meets
the C.W. Bill Young Cell Transplantation Program requirements to provide relevant scientific information
not containing individually identifiable information available to the public in the form of summaries and
data sets. 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
information collection is 0915-0310 and it is valid until 10/31/2022. This information collection is voluntary
under The Stem Cell Therapeutic and Research Act of 2005, Public Law (Pub. L.) 109–129, as amended
by the Stem Cell Therapeutic and Research Reauthorization Act of 2010, Public Law 111–264 (the Act)
and the Stem Cell Therapeutic and Research Reauthorization Act of 2015, Public Law 114-104. Public
reporting burden for this collection of information is estimated to average 0.68 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 14N136B, Rockville, Maryland, 20857 or
[email protected].
Date Received:
Center Identification
CIBMTR Center Number: ___ ___ ___ ___ ___
EBMT Code (CIC): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Recipient Identification
CIBMTR Research ID (CRID): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Event date: __ __ __ __ / __ __ / __ __
YYYY
MM
DD
CIBMTR Form 2400 R8 (page 1 of 26). Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Recipient Information
Date of birth: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Sex
Male
Female
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Not applicable (not a resident of the USA)
Unknown
Race (check all that apply)
White – Go to question 5
Black or African American– Go to question 5
Asian– Go to question 5
American Indian or Alaska Native– Go to question 5
Native Hawaiian or Other Pacific Islander– Go to question 5
Not reported – Go to question 6
Unknown– Go to question 6
Race detail (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
African American
CIBMTR Form 2400 R8 (page 2 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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
Korean
Chinese
Vietnamese
Other Southeast Asian
Guamanian
Hawaiian
Samoan
Other Pacific Islander
Unknown
Country of primary residence
Afghanistan
Ghana
Palau
Aland Islands
Gibraltar
Palestine, State of
Albania
Greece
Panama
Algeria
Greenland
Papua New Guinea
American Samoa
Grenada
Paraguay
Andorra
Guadeloupe
Peru
Angola
Guam
Philippines
Anguilla
Guatemala
Pitcairn Islands
Antarctica
Guernsey
Poland
Antigua and Barbuda
Guinea
Portugal
Argentina
Guinea-Bissau
Puerto Rico
Armenia
Guyana
Qatar
Aruba
Haiti
Reunion
Australia
Romania
Austria
Heard Island and McDonald
Islands
Russia
Holy See
CIBMTR Form 2400 R8 (page 3 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Azerbaijan
Honduras
Rwanda
Bahamas
Hong Kong
Saint Barthelemy
Bahrain
Hungary
Saint Helena
Bangladesh
Iceland
Saint Kitts and Nevis
Barbados
India
Saint Lucia
Belarus
Indonesia
Saint Martin, French
Belgium
Iran
Saint Pierre and Miquelon
Belize
Iraq
Benin
Ireland
Saint Vincent and the
Grenadines
Bermuda
Isle of Man
Samoa
Bhutan
Israel
San Marino
Bolivia
Italy
Sao Tome and Principe
Bonaire, Sint Eustatius and
Saba
Jamaica
Saudi Arabia
Japan
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten, Dutch
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South
Sandwich Islands
Bosnia and Herzegovina
Jersey
Botswana
Jordan
Bouvet Island
Kazakhstan
Brazil - Go to question 7
Kenya
British Indian Ocean Territory
Kiribati
British Virgin Islands
Kuwait
Brunei Darussalam
Kyrgyzstan
Bulgaria
Laos
Burkina Faso
Latvia
Burundi
Lebanon
Cambodia
Lesotho
Cameroon
Liberia
Canada - Go to question 8
South Korea
Libya
Cape Verde
South Sudan
Liechtenstein
Cayman Islands
Spain
Lithuania
Central African Republic
Sri Lanka
Luxembourg
Chad
Sudan
Macau
Chile
Suriname
Macedonia
China
Svalbard and Jan Mayen
Madagascar
Christmas Island
Swaziland
Malawi
Cocos (Keeling) Islands
Sweden
Malaysia
Colombia
Switzerland
Maldives
Syria
CIBMTR Form 2400 R8 (page 4 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Comoros
Mali
Taiwan
Congo, Democratic Republic
of the
Malta
Tajikistan
Marshall Islands
Tanzania
Congo, Republic of the
Martinique
Thailand
Cook Islands
Mauritania
Timor-Leste
Costa Rica
Mauritius
Togo
Cote d’Ivoire
Mayotte
Tokelau
Croatia
Mexico
Tonga
Cuba
Micronesia
Trinidad and Tobago
Curacao
Moldova
Tunisia
Cyprus
Monaco
Turkey
Czech Republic
Mongolia
Turkmenistan
Denmark
Montenegro
Turks and Caicos Islands
Djibouti
Montserrat
Tuvalu
Dominica
Morocco
Uganda
Dominican Republic
Mozambique
Ukraine
Ecuador
Myanmar
United Arab Emirates
Egypt
Namibia
El Salvador
Nauru
Equatorial Guinea
United Kingdom (England,
Wales, Scotland, Northern
Ireland)
Nepal
Eritrea
Netherlands
United States - Go to
question 9
Estonia
Netherlands Antilles
Ethiopia
New Caledonia
United States Minor Outlying
Islands
Falkland Islands
New Zealand
United States Virgin Islands
Faroe Islands
Nicaragua
Uruguay
Fiji
Niger
Uzbekistan
Finland
Nigeria
Vanuatu
France
Niue
Venezuela
French Guiana
Norfolk Island
Vietnam
French Polynesia
North Korea
Wallis and Futuna Islands
French Southern Territories
Northern Mariana Islands
Western Sahara
Gabon
Norway
Yemen
Gambia
Oman
Zambia
Georgia
Pakistan
Zimbabwe
Germany
CIBMTR Form 2400 R8 (page 5 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
State of residence of recipient (for residents of Brazil) _________________________ - Go to question
10
Acre
Maranhão
Rio de Janeiro
Alagoas
Mato Grosso
Rio Grande do Norte
Amapá
Mato Grosso do Sul
Rio Grande do Sul
Amazonas
Minas Gerais
Rondônia
Bahia
Pará
Roraima
Ceará
Paraíba
Santa Catarina
Distrito Federal
Paraná
São Paulo
Espírito Santo
Pernambuc
Sergipe
Goiás
Piauí
Tocantins
Province or territory of residence of recipient (for residents of Canada) ____________________- Go to
question 10
Provinces
Territories
Alberta
Nova Scotia
Northwest Territories
British Columbia
Ontario
Nunavut
Manitoba
Prince Edward Island
Yukon
New Brunswick
Quebec
Newfoundland and Labrador
Saskatchewan
State of residence of recipient (for residents of USA) ______________________
☐ Alabama
☐ Kentucky
☐ North Dakota
☐ Arizona
☐ Maine
☐ Oklahoma
☐ Alaska
☐ Arkansas
☐ California
☐ Colorado
☐ Connecticut
☐ Delaware
☐ District of Columbia
☐ Louisiana
☐ Maryland
☐ Massachusetts
☐ Michigan
☐ Minnesota
☐ Mississippi
☐ Missouri
☐ Ohio
☐ Oregon
☐ Pennsylvania
☐ Rhode Island
☐ South Carolina
☐ South Dakota
☐ Tennessee
CIBMTR Form 2400 R8 (page 6 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
☐ Florida
☐ Montana
☐ Texas
☐ Hawaii
☐ Nevada
☐ Vermont
☐ Georgia
☐ Nebraska
☐ Idaho
☐ Utah
☐ New Hampshire
☐ Illinois
☐ New Jersey
☐ Indiana
☐ New Mexico
☐ Iowa
☐ Washington
☐ West Virginia
☐ New York
☐ Kansas
☐ Virginia
☐ Wisconsin
☐ North Carolina
☐ Wyoming
NMDP Recipient ID (RID): __ __ __ __ __ __ __
Zip or postal code for place of recipient’s residence (USA and Canada recipients only): ___ ___ ___ ___ ___
______ ___ ___ ___
Specify blood type (of recipient) (For allogeneic HCTs only)
A
B
AB
O
Specify Rh factor (of recipient) (For allogeneic HCTs only)
Positive
Negative
Has the recipient signed an IRB / ethics committee (or similar body) approved consent form to donate research
blood samples to the NMDP / CIBMTR? (For allogeneic HCTs only)
Yes (recipient consented) – Go to question 15
No (recipient declined) - Go to question 18
Not approached - Go to question 18
Not applicable (center not participating) - Go to question 18
Date form was signed: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Did the recipient submit a research sample to the NMDP/CIBMTR repository? (Related donors only)
Yes – Go to question 17
CIBMTR Form 2400 R8 (page 7 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
No – Go to question 18
Research sample recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Is the recipient participating in a clinical trial? (clinical trial sponsors that use CIBMTR forms to capture outcomes
data)
Yes - Go to question 19
No – Go to question 24
Study Sponsor
BMT CTN – Go to question 21
RCI BMT – Go to question 21
PIDTC – Go to question 21
USIDNET – Go to question 22
COG – Go to question 22
Other sponsor – Go to question 20
Specify other sponsor: ________________________________ - Go to question 22
Study ID Number: _____________________
Subject ID: ______________________
Specify the ClinicalTrials.gov identification number: NCT __ __ __ __ __ __ __ __
Copy questions 19-23 to report participation in more than one study.
Hematopoietic Cellular Transplant (HCT) and Cellular Therapy
Is a subsequent HCT planned as part of the overall treatment protocol? (not as a reaction to post-HCT disease
assessment) (For autologous HCTs only)
Yes – Go to question 25
No – Go to question 26
Specify subsequent HCT planned
Autologous
Allogeneic
Has the recipient ever had a prior HCT?
Yes – Go to question 27
No – Go to question 38
CIBMTR Form 2400 R8 (page 8 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify the number of prior HCTs: ___ ___
Were all prior HCTs reported to the CIBMTR?
Yes – Go to question 33
No – Go to question 29
Unknown – Go to question 33
Copy and complete questions 29- 32 to report all prior HCTs that have not yet been reported to the
CIBMTR
Date of the prior HCT: ___ ___ ___ ___ — ___ ___ — ___ ___ Date estimated
YYYY
MM
DD
Was the prior HCT performed at a different institution?
Yes – Go to question 31
No – Go to question 32
Specify the institution that performed the last HCT
Name: _______________________________________________________________
City:__________________________________________________________________
State: _________________________________________________________________
Country: _______________________________________________________________
What was the HPC source for the prior HCT? (check all that apply)
Autologous
Allogeneic, unrelated
Allogeneic, related
Reason for current HCT
Graft failure / insufficient hematopoietic recovery – Go to question 34
Persistent primary disease– Go to question 38
Recurrent primary disease– Go to question 35
Planned subsequent HCT, per protocol– Go to question 38
New malignancy (including PTLD and EBV lymphoma) – Go to question 36
Insufficient chimerism– Go to question 38
Other– Go to question 37
Date of graft failure / rejection: ___ ___ ___ ___ — ___ ___ — ___ ___ – Go to question 38
CIBMTR Form 2400 R8 (page 9 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
YYYY
MM
DD
Date of relapse: ___ ___ ___ ___ — ___ ___ — ___ ___ – Go to question 38
YYYY
MM
DD
Date of secondary malignancy: ___ ___ ___ ___ — ___ ___ — ___ ___ – Go to question 38
YYYY
MM
DD
Specify other reason: __________________________ - Go to question 38
Has the recipient ever had a prior cellular therapy? (do not include DLIs)
Yes – Go to question 39
No – Go to question 44
Unknown– Go to question 44
Were all prior cellular therapies reported to the CIBMTR?
Yes – Go to question 44
No – Go to question 40
Unknown– Go to question 44
Copy and complete questions 40-43 to report all prior cellular therapies that have not yet been
reported to the CIBMTR
Date of the prior cellular therapy: __ __ __ __ -- __ __ -- __ __
YYYY
MM
DD
Was the cellular therapy performed at a different institution?
Yes – Go to question 42
No – Go to question 43
Name: ___________________________________________________________________
City: ____________________________________________________________________
State: ___________________________________________________________________
Country: _________________________________________________________________
Specify the source(s) for the prior cellular therapy (check all that apply)
Autologous
Allogeneic, unrelated
Allogeneic, related
CIBMTR Form 2400 R8 (page 10 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Donor Information
Multiple donors?
Yes – Go to question 45
No - Go to question 46
Specify number of donors: ___ ___
To report more than one donor, copy questions 46-82 and complete for each donor.
Specify donor
Autologous
Allogeneic, related
Allogeneic, unrelated
Specify product type (check all that apply)
Bone marrow
PBSC
Single cord blood unit
Other product– Go to question 48
Specify other product: _______________________________________
Is the product genetically modified? If autologous, go to question 77. If allogeneic related, go to question 50.
If allogeneic unrelated, go to question 54.
Yes
No
Specify the related donor type
Syngeneic (monozygotic twin) – Go to question 55
HLA-identical sibling (may include non-monozygotic twin) – Go to question 55
HLA-matched other relative (does NOT include a haplo-identical donor) - Go to question 51
HLA-mismatched relative– Go to question 51
Specify the biological relationship of the donor to the recipient
Mother
Father
Child
Sibling
CIBMTR Form 2400 R8 (page 11 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Fraternal twin
Maternal aunt
Maternal uncle
Maternal cousin
Paternal aunt
Paternal uncle
Paternal cousin
Grandparent
Grandchild
Other biological relative – Go to question 52
Specify other biological relative: _________________________– Go to question 53
Degree of mismatch (related donors only)
HLA-mismatched 1 allele– Go to question 55
HLA-mismatched >2 alleles (does include haplo-identical donor) – Go to question 55
Specify unrelated donor type
HLA matched unrelated
HLA mismatched unrelated
Did NMDP / Be the Match facilitate the procurement, collection, or transportation of the product?
Yes
No
Was this donor used for any prior HCTs? (for this recipient)
Yes
No
NMDP cord blood unit ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – Go to question 72
Non-NMDP unrelated donor ID: (not applicable for related donors)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - Go to question 63
Non-NMDP cord blood unit ID: (include related and autologous CBUs)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - Go to question 61
CIBMTR Form 2400 R8 (page 12 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Global Registration Identifier for Donors (GRID): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __
NMDP donor, go to question 72
Non-NMDP unrelated donor, go to question 63
Is the CBU ID also the ISBT DIN number?
Yes – Go to question 63
No – Go to question 62
Unknown– Go to question 63
Specify the ISBT DIN number: ____________________________________
Registry or UCB Bank ID: ___ ___ ___ ___ - If ‘Other registry’ go to 64, otherwise go to question 65
Specify other Registry or UCB Bank: _______________________________ - Go to question 65
Donor date of birth
Known – Go to question 66
Unknown – Go to question 67
Donor date of birth: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 69
YYYY
MM
DD
Donor age
Known – Go to question 68
Unknown – Go to question 69
Donor age: ___ ___
Months (use only if less than 1 year old)
Years
Donor sex
Male
Female
Specify blood type (donor) (non-NMDP allogeneic donors only)
A
B
AB
O
CIBMTR Form 2400 R8 (page 13 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify Rh factor (donor) (non-NMDP allogeneic donors only)
Positive
Negative
Donor CMV-antibodies (IgG or Total) (Allogeneic HCTs only)
Reactive
Non-reactive
Indeterminate
Not done
Not applicable (cord blood unit)
Has the donor signed an IRB / ethics committee (or similar body) approved consent form to donate research blood
samples to the NMDP / CIBMTR? (Related donors only)
Yes (donor consented) – Go to question 74
No (donor declined) - Go to question 77
Not approached - Go to question 77
Not applicable (center not participating) - Go to question 77
Date form was signed: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Did the donor submit a research sample to the NMDP/CIBMTR repository? (Related donors only)
Yes – Go to question 76
No – Go to question 77
Research sample donor ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify number of products infused from this donor: ___ ___
Specify the number of these products intended to achieve hematopoietic engraftment: ___ ___
Questions 79-80 are for autologous HCT recipients only.
What agents were used to mobilize the autologous recipient for this HCT? (check all that apply)
G-CSF (filgrastim, Neupogen)
Pegylated G-CSF (pegfilgrastim, Neulasta)
Plerixafor (Mozobil)
Combined with chemotherapy
CIBMTR Form 2400 R8 (page 14 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
Anti-CD20 (rituximab, Rituxan)
Other agent– Go to question 80
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify other agent: ___________________
Name of product: (gene therapy recipients)
Other name
Specify other name: ____________________
To report more than one donor, copy questions 46-82 and complete for each donor.
Clinical Status of Recipient Prior to the Preparative Regimen (Conditioning)
What scale was used to determine the recipient’s functional status?
Karnofsky (recipient age ≥ 16 years) – Go to question 84
Lansky (recipient age ≥ 1 year and < 16 years) – Go to question 85
Performance score prior to the preparative regimen:
Karnofsky Scale (recipient age ≥ 16 years)
100 Normal; no complaints; no evidence of disease - Go to question 86
90 Able to carry on normal activity - Go to question 86
80 Normal activity with effort - Go to question 86
70 Cares for self; unable to carry on normal activity or to do active work - Go to question 86
60 Requires occasional assistance but is able to care for most needs - Go to question 86
50 Requires considerable assistance and frequent medical care - Go to question 86
40 Disabled; requires special care and assistance - Go to question 86
30 Severely disabled; hospitalization indicated, although death not imminent - Go to question 86
20 Very sick; hospitalization necessary - Go to question 86
10 Moribund; fatal process progressing rapidly - Go to question 86
Lansky Scale (recipient age ≥ 1 year and < 16 years)
100 Fully active
90 Minor restriction in physically strenuous play
80 Restricted in strenuous play, tires more easily, otherwise active
70 Both greater restrictions of, and less time spent in, active play
CIBMTR Form 2400 R8 (page 15 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
60 Ambulatory up to 50% of time, limited active play with assistance / supervision
50 Considerable assistance required for any active play; fully able to engage in quiet play
40 Able to initiate quiet activities
30 Needs considerable assistance for quiet activity
20 Limited to very passive activity initiated by others (e.g., TV)
10 Completely disabled, not even passive play
Recipient CMV-antibodies (IgG or Total)
Reactive
Non-reactive
Indeterminate
Not done
Comorbid Conditions
Has the patient been infected with COVID-19 (SARS-CoV-2) based on a positive test result at any time prior to
the start of the preparative regimen / infusion?
Yes – Go to question 88
No – Go to question 90
Did the patient require hospitalization for management of COVID-19 (SARS-CoV-2) infection?
Yes – Go to question 89
No – Go to question 90
Was mechanical ventilation given for COVID-19 (SARS-CoV-2) infection?
Yes
No
Is there a history of mechanical ventilation (excluding COVID-19 (SARS-CoV-2))?
Yes
No
Is there a history of invasive fungal infection?
Yes
No
Glomerular filtration rate (GFR) before start of preparative regimen (pediatric only)
Known- Go to question 93
Unknown- Go to question 94
CIBMTR Form 2400 R8 (page 16 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Glomerular filtration rate (GFR): __ __ __ mL/min/1.732
Does the recipient have known complex congenital heart disease? (corrected or uncorrected) (excluding simple
ASD, VSD, or PDA repair) (pediatric only)
Yes
No
Were there any co-existing diseases or organ impairment present according to the HCT comorbidity index (HCTCI)? (Source: Sorror, M. L. (2013). How I assess comorbidities before hematopoietic cell transplantation. Blood,
121(15), 2854-2863.)
Yes- Go to question 96
No- Go to question 102
Specify co-existing diseases or organ impairment (check all that apply)
Arrhythmia - Any history of atrial fibrillation or flutter, sick sinus syndrome, or ventricular
arrhythmias requiring treatment
Cardiac -Any history of coronary artery disease (one or more vessel-coronary artery stenosis
requiring medical treatment, stent, or bypass graft), congestive heart failure, myocardial
infarction, OR ejection fraction ≤ 50% on the most recent test
Cerebrovascular disease -Any history of transient ischemic attack, subarachnoid hemorrhage
or cerebral thrombosis, embolism, or hemorrhage
Diabetes -Requiring treatment with insulin or oral hypoglycemic drugs in the last 4 weeks but
not diet alone
Heart valve disease -At least a moderate to severe degree of valve stenosis or insufficiency as
determined by Echo; prosthetic mitral or aortic valve; or symptomatic mitral valve prolapse
Hepatic, mild - Bilirubin > upper limit of normal to 1.5 × upper limit of normal, or AST/ALT >
upper limit of normal to 2.5 × upper limit of normal at the time of transplant OR any history of
hepatitis B or hepatitis C infection
Hepatic, moderate/severe -Liver cirrhosis, bilirubin > 1.5 × upper limit of normal, or AST/ALT >
2.5 × upper limit of normal
Infection -Includes a documented infection, fever of unknown origin, or pulmonary nodules
suspicious for fungal pneumonia or a positive PPD test requiring prophylaxis against
tuberculosis. Patients must have started antimicrobial treatment before Day 0 with
continuation of antimicrobial treatment after Day 0
Inflammatory bowel disease -Any history of Crohn’s disease or ulcerative colitis requiring
treatment
Obesity -Patients older than 18 years with a body mass index (BMI) > 35 kg/m2 prior to the
start of conditioning or a BMI of the 95th percentile of higher for patients aged 18 years or
younger
Peptic ulcer -Any history of peptic (gastric or duodenal) ulcer confirmed by endoscopy or
radiologic diagnosis requiring treatment
Psychiatric disturbance -Presence of any mood (e.g., depression), anxiety, or other psychiatric
disorder (e.g. bipolar disorder or schizophrenia) requiring continuous treatment in the last 4
weeks
CIBMTR Form 2400 R8 (page 17 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Pulmonary, moderate -Corrected diffusion capacity of carbon monoxide and/or FEV1 of 6680% or dyspnea on slight activity attributed to pulmonary disease at transplant
Pulmonary, severe -Corrected diffusion capacity of carbon monoxide and/or FEV1 of ≤ 65% or
dyspnea at rest attributed to pulmonary disease or the need for intermittent or continuous
oxygen during the 4 weeks prior to transplant
Renal, moderate / severe -Serum creatinine > 2 mg/dL or > 177 μmol/L; on dialysis during the 4
weeks prior to transplant; OR prior renal transplantation -go to question 97
Rheumatologic -Any history of a rheumatologic disease (e.g., systemic lupus erythematosis,
rheumatoid arthritis, polymyositis, mixed connective tissue disease, or polymyalgia
rheumatica, etc.) requiring treatment. (Do NOT include degenerative joint disease,
osteoarthritis)
Prior malignancy-Treated at any time point in the patient’s past history, other than the primary
disease for which this infusion is being performed -go to question 98
Was the recipient on dialysis immediately prior to start of preparative regimen?
Yes
No
Unknown
Specify prior malignancy (check all that apply)
Breast cancer
Central nervous system (CNS) malignancy (e.g., glioblastoma, astrocytoma)
Gastrointestinal malignancy (e.g., colon, rectum, stomach, pancreas, intestine, esophageal)
Genitourinary malignancy (e.g., kidney, bladder, ovary, testicle, genitalia, uterus, cervix,
prostate)
Leukemia (includes acute or chronic leukemia)
Lung cancer
Lymphoma (includes Hodgkin & non-Hodgkin lymphoma)
MDS / MPN
Melanoma
Multiple myeloma / plasma cell disorder (PCD)
Oropharyngeal cancer (e.g., tongue, buccal mucosa)
Sarcoma
Thyroid cancer
Other skin malignancy (basal cell, squamous)- go to question 99
Other hematologic malignancy -go to question 100
Other solid tumor -go to question 101
Specify other skin malignancy: (prior) _______________________________
Specify other hematologic malignancy: (prior) _____________________________
CIBMTR Form 2400 R8 (page 18 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Specify other solid tumor: (prior) _______________
Use results within 4 weeks prior to the start of the preparative regimen, report results from the test performed
closest to the start date. Biomarkers according to the augmented HCT comorbidity index. (Source: Biol Blood
Marrow Transplant. 2015 Aug; 21(8): 1418–1424)
Serum ferritin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date)
Known – Go to question 103
Unknown – Go to question 106
___ ___ ___ ___ ___ ng/mL (μg/L)
Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Upper limit of normal for your institution: ___ ___ ___ ___ ___
Serum albumin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date)
Known – Go to question 107
Unknown – Go to question 109
___ ___ ● ___
g/dL
g/L
Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Platelets (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date)
Known – Go to question 110
Unknown – Go to question 112
___ ___ ___ ___ ___ ___ ___
x 109/L (x 103/mm3)
x 106/L
Were platelets transfused < 7 days before date of test?
Yes
No
Unknown
CIBMTR Form 2400 R8 (page 19 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Did the recipient have a prior solid organ transplant?
Yes- Go to question 113
No- Go to question 116
Specify organ:
Bowel
Heart
Kidney(s)
Liver
Lung(s)
Pancreas
Other organ- Go to question 114
Specify other organ: _______________________________
Year of prior solid organ transplant: ___ ___ ___ ___
YYYY
Copy and complete questions 113-115 for each prior solid organ transplant
Pre-HCT Preparative Regimen (Conditioning)
Height at initiation of pre-HCT preparative regimen: ___ ___ ___
inches
centimeters
Actual weight at initiation of pre-HCT preparative regimen: ___ ___ ___ . ___
pounds
kilograms
Was a pre-HCT preparative regimen prescribed?
Yes – Go to question 119
No – Go to question 132
Classify the recipient’s prescribed preparative regimen (Allogeneic HCTs only)
Myeloablative
Non-myeloablative (NST)
Reduced intensity (RIC)
Was irradiation planned as part of the pre-HCT preparative regimen?
Yes – Go to question 121
No – Go to question 126
CIBMTR Form 2400 R8 (page 20 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
What was the prescribed radiation field?
Total body – Go to question 122
Total body by intensity-modulated radiation therapy (IMRT) – Go to question 122
Total lymphoid or nodal regions – Go to question 122
Thoracoabdominal region – Go to question 122
Total prescribed dose: (dose per fraction x total number of fractions) ___ ___ ___ ___ . ___ Gy
cGy
Date started: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Was the radiation fractionated?
Yes – Go to question 125
No – Go to question 126
Total number of fractions: ___ ___
Indicate the total prescribed cumulative dose for the preparative regimen
Drug (drop down list)
Bendamustine
Busulfan
Carboplatin
Carmustine (BCNU)
CCNU (Lomustine)
Clofarabine (Clolar)
Cyclophosphamide (Cytoxan)
Cytarabine (Ara-C)
Etoposide (VP-16, VePesid)
Fludarabine
Gemcitabine
Ibritumomab tiuxetan (Zevalin)
Ifosfamide
Melphalan (L-Pam)
Methylprednisolone (Solu-Medrol)
Pentostatin
Propylene glycol-free melphalan (Evomela)
CIBMTR Form 2400 R8 (page 21 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Rituximab (Rituxan)
Thiotepa
Tositumomab (Bexxar)
Treosulfan
Other drug -go to question 127
Specify other drug: ___________
Total prescribed dose: __ __ __ __ __. __ mg/m2
mg/kg
AUC (mg x h/L)
AUC (µmol x min/L)
CSS (ng/mL)
Date started: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
Specify administration (busulfan only)
Oral
IV
Both
Copy and complete question 126-130 to report each drug given for the preparative regimen
Additional Drugs Given in the Peri-Transplant Period
ALG, ALS, ATG, ATS
Yes – Go to question 132
No – Go to question 135
Total prescribed dose: ___ ___ ___ ___ ___ mg/kg
Specify source
ATGAM (horse) – Go to question 135
ATG – Fresenius (rabbit) – Go to question 135
Thymoglobulin (rabbit) – Go to question 135
Other – Go to question 134
Specify other source: _____________________
CIBMTR Form 2400 R8 (page 22 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Alemtuzumab (Campath)
Yes – Go to question 136
No – Go to question 137
Total prescribed dose: __ __ __ __ . __ mg/m2
mg/kg
mg
Defibrotide
Yes
No
KGF
Yes
No
Ursodiol
Yes
No
GVHD Prophylaxis
This section is to be completed for allogeneic HCTs only; autologous HCTs continue with question 143.
Was GVHD prophylaxis planned?
Yes - Go to question 141
No - Go to question 143
Specify drugs / intervention (check all that apply)
Abatacept
Anti CD 25 (Zenapax, Daclizumab, AntiTAC)
Blinded randomized trial
Bortezomib
CD34 enriched (CD34+ selection)
Corticosteroids (systemic)
Cyclophosphamide (Cytoxan)
CIBMTR Form 2400 R8 (page 23 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Cyclosporine (CSA, Neoral, Sandimmune)
Extra-corporeal photopheresis (ECP)
Ex-vivo T-cell depletion
Filgotinib
Maraviroc
Methotrexate (MTX) (Amethopterin)
Mycophenolate mofetil (MMF) (CellCept)
Ruxolotinib
Sirolimus (Rapamycin, Rapamune)
Tacrolimus (FK 506)
Tocilizumab
Other agent-go to question 142
Specify other agent: ______________ (do not report ATG, campath)
Post-HCT Disease Therapy Planned as of Day 0
Is additional post-HCT therapy planned?
Yes - Go to question 144
No - Go to First Name
Questions 144-145 are optional for non-U.S. centers
Specify post-HCT therapy planned (check all that apply)
Azacytidine (Vidaza)
Blinatumomab
Bortezomib (Velcade)
Bosutinib
Brentuximab
Carfilzomib
Cellular therapy (e.g. DCI, DLI)
Crenolanib
Daratumumab
Dasatinib
Decitabine
Elotuzumab
Enasidenib
CIBMTR Form 2400 R8 (page 24 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Gilteritinib
Ibrutinib
Imatinib mesylate (Gleevec, Glivec)
Intrathecal therapy (chemotherapy)
Ivosidenib
Ixazomib
Lenalidomide (Revlimid)
Lestaurtinib
Local radiotherapy
Midostaurin
Nilotinib
Obinutuzumab
Pacritinib
Ponatinib
Quizartinib
Rituximab (Rituxan, MabThera)
Sorafenib
Sunitinib
Thalidomide (Thalomid)
Other therapy- Go to question 145
Unknown
Specify other therapy: ____________________________
Prior Exposure: Potential Study Eligibility
Selecting any option(s) below may generate an additional supplemental form.
Specify if the recipient received any of the following (at any time prior to HCT / infusion) (check all that apply)
Blinatumomab (Blincyto)
Gemtuzumab ozogamicin (Mylotarg)
Inotuzumab ozogamicin (Besponsa)
Adienne Tepadina®
Mogamulizumab (Poteligeo)
None of the above
CIBMTR Form 2400 R8 (page 25 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
CIBMTR Center Number: ___ ___ ___ ___ ___
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
First Name: ____________________________________________________________________________
Last Name:
____________________________________________________________________________
E-mail address: _________________________________________________________________________________
Date: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY
MM
DD
CIBMTR Form 2400 R8 (page 26 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.
| File Type | application/pdf |
| Author | Monique Ammi |
| File Modified | 2021-03-17 |
| File Created | 2021-01-22 |