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pdfRecipient Death Data
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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 Type | application/pdf |
File Modified | 2021-01-08 |
File Created | 2020-04-16 |