3B HLA - 2005 R7 (current approved for)

Confirmation of HLA Typing

OMB No: 0915-0310
Expiration Date: 10/31/2022

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 hour 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 14N39, Rockville, Maryland, 20857.

Date Received:

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

MM

DD

Product Identifiers:
Registry donor ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Non-NMDP cord blood unit ID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
GRID: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
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 January, 2020. Last Updated January, 2021.
Copyright (c) 2020 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.
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.

Locus A

☐ Known
☐ Unknown

4.

First A* allele designations

Second A* allele designations

5.

Locus B

☐ Known
☐ Unknown

6.

First B* allele designations

Second B* allele designations

7.

Locus C

☐ Known
☐ Unknown

8.

First C* allele designations

Second C* allele designations

CIBMTR Form 2005 revision 7 (page 2 of 12). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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
30. Specificity – 2nd antigen

☐ B5
☐ B7
☐ B703
☐ B8
☐ B12

CIBMTR Form 2005 revision 7 (page 7 of 12). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 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.
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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 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

☐ Yes
☐ Yes

34. Specificity Bw4 present?
35. Specificity Bw6 present?

☐ No
☐ No

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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

☐ DQ9(3)
☐ DQX
44. 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). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form released January, 2020.
Last Updated January, 2021. Copyright (c) 2020 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.