9 Form 2900 R4 - CURRENT

Stem Cell Therapeutic Outcomes Database

Form 2900 R4 - CURRENT

2-Year Post-TED

OMB: 0915-0310

Document [pdf]
Download: pdf | pdf
Recipient Death Data

Registry Use Only
Sequence Number:
Date Received:

CIBMTR Center Number: ___ ___ ___ ___ ___ 	
CIBMTR Research ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 	
Event date: __ __ __ __ / __ __ / __ __
	
YYYY
MM
DD	

CIBMTR Form 2900 revision 4 (page 1 of 4). Form released January, 2019. Last Updated May, 2020.
Copyright (c) 2019 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___	

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

Recipient Death
1.	
	

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

2.	

Was cause of death confirmed by autopsy?

	

☐ Yes
☐ Autopsy pending
☐ No
☐ Unknown

4.	

Primary cause of death

	
	
	

☐ Date estimated

3.	

Was documentation submitted to the CIBMTR? (autopsy report)	

☐ Yes	

☐ No

☐ Recurrence / persistence / progression of disease for which the HCT or cellular therapy was performed - Go to question 6
	
☐ Acute GVHD - Go to question 6
	
☐ Chronic GVHD - Go to question 6
	
☐ Graft rejection or failure - Go to question 6
	☐ Cytokine release syndrome - Go to question 6
	

	
	Infection

☐ Infection, organism not identified - Go to question 6
	
☐ Bacterial infection - Go to question 6
	
☐ Fungal infection - Go to question 6
	
☐ Viral infection - Go to question 6
	
☐ COVID-19 (SARS-CoV-2) - Go to question 6
	☐ Protozoal infection - Go to question 6
	☐ Other infection - Go to question 5
	

	Pulmonary

☐ Idiopathic pneumonia syndrome (IPS) - Go to question 6
	
☐ Pneumonitis due to Cytomegalovirus (CMV) - Go to question 6
	
☐ Pneumonitis due to other virus - Go to question 6
	
☐ Other pulmonary syndrome (excluding pulmonary hemorrhage) - Go to question 5
	☐ Diffuse alveolar damage (without hemorrhage) - Go to question 6
	☐ Acute respiratory distress syndrome (ARDS) (other than IPS) - Go to question 6
	

	

Organ failure (not due to GVHD or infection)

☐ Liver failure (not VOD) - Go to question 6
☐ Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) - Go to question 6
	
☐ Cardiac failure - Go to question 6
	
☐ Pulmonary failure - Go to question 6
	☐ Central nervous system (CNS) failure - Go to question 6
	☐ Renal failure - Go to question 6
	
☐ Gastrointestinal (GI) failure (not liver) - Go to question 6
	☐ Multiple organ failure - Go to question 5
	☐ Other organ failure - Go to question 5
	
	

	Malignancy
	

☐ New malignancy (post-HCT or post-cellular therapy) - Go to question 6

	
☐ Prior malignancy (malignancy initially diagnosed prior to HCT or cellular therapy, other than the malignancy for which the HCT or cellular 	
		 therapy was performed) - Go to question 6

CIBMTR Form 2900 revision 4 (page 2 of 4). Form released January, 2019. Last Updated May, 2020.
Copyright (c) 2019 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___	

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

	Hemorrhage

☐ Pulmonary hemorrhage - Go to question 6
☐ Diffuse alveolar hemorrhage (DAH) - Go to question 6
	
☐ Intracranial hemorrhage - Go to question 6
	
☐ Gastrointestinal hemorrhage - Go to question 6
	☐ Hemorrhagic cystitis - Go to question 6
	☐ Other hemorrhage - Go to question 5
	
	

	Vascular
	
	
	
	

☐ Thromboembolic - Go to question 6
☐ Disseminated intravascular coagulation (DIC) - Go to question 6
☐ Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP) / Hemolytic Uremic Syndrome (HUS)) - Go to question 6
☐ Other vascular - Go to question 5

	Other
	
	
	

☐ Accidental death - Go to question 6
☐ Suicide - Go to question 6
☐ Other cause - Go to question 5
5.	Specify:______________________________________________________________

Contributing Cause of Death
6. 	 Contributing cause of death (check all that apply)

☐ Recurrence / persistence / progression of disease for which the HCT or cellular therapy was performed - Go to First Name
☐ Acute GVHD - Go to First Name
	
☐ Chronic GVHD - Go to First Name
	
☐ Graft rejection or failure - Go to First Name
	☐ Cytokine release syndrome - Go to First Name
	
	

	
	Infection

☐ Infection, organism not identified - Go to First Name
	
☐ Bacterial infection - Go to First Name
	
☐ Fungal infection - Go to First Name
	
☐ Viral infection - Go to First Name
	
☐ COVID-19 (SARS-CoV-2) - Go to First Name
	☐ Protozoal infection - Go to First Name
	☐ Other infection - Go to question 7
	

	Pulmonary

☐ Idiopathic pneumonia syndrome (IPS) - Go to First Name
	
☐ Pneumonitis due to Cytomegalovirus (CMV) - Go to First Name
	
☐ Pneumonitis due to other virus - Go to First Name
	
☐ Other pulmonary syndrome (excluding pulmonary hemorrhage) - Go to question 7
	☐ Diffuse alveolar damage (without hemorrhage) - Go to First Name
	☐ Acute respiratory distress syndrome (ARDS) (other than IPS) - Go to First Name
	

CIBMTR Form 2900 revision 4 (page 3 of 4). Form released January, 2019. Last Updated May, 2020.
Copyright (c) 2019 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___	
	

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

Organ failure (not due to GVHD or infection)

☐ Liver failure (not VOD) - Go to First Name
☐ Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) - Go to First Name
	
☐ Cardiac failure - Go to First Name
	
☐ Pulmonary failure - Go to First Name
	☐ Central nervous system (CNS) failure - Go to First Name
	☐ Renal failure - Go to First Name
	
☐ Gastrointestinal (GI) failure (not liver) - Go to First Name
	☐ Multiple organ failure - Go to question 7
	☐ Other organ failure - Go to question 7
	
	

	Malignancy
	

☐ New malignancy (post-HCT or post-cellular therapy) - Go to First Name

	
☐ Prior malignancy (malignancy initially diagnosed prior to HCT or cellular therapy, other than the malignancy for which the HCT or cellular 	
		 therapy was performed) - Go to First Name
	Hemorrhage

☐ Pulmonary hemorrhage - Go to First Name
	
☐ Diffuse alveolar hemorrhage (DAH) - Go to First Name
	
☐ Intracranial hemorrhage - Go to First Name
	
☐ Gastrointestinal hemorrhage - Go to First Name
	☐ Hemorrhagic cystitis - Go to First Name
	☐ Other hemorrhage - Go to question 7
	

	Vascular
	
	
	
	

☐ Thromboembolic - Go to First Name
☐ Disseminated intravascular coagulation (DIC) - Go to First Name
☐ Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)) - Go to First Name
☐ Other vascular - Go to question 7

	Other
	
	
	

☐ Accidental death - Go to First Name
☐ Suicide - Go to First Name
☐ Other cause - Go to question 7
7.	Specify:______________________________________________________________

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

CIBMTR Form 2900 revision 4 (page 4 of 4). Form released January, 2019. Last Updated May, 2020.
Copyright (c) 2019 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.


File Typeapplication/pdf
File Modified2021-01-08
File Created2020-04-16

© 2024 OMB.report | Privacy Policy