Draft 2402 r3- Pre-TED Disease (OMB doc 12-05-17)

Disease Classification

^{OMB No: 0915-0310}

Expiration Date: 1/31/2020

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 is estimated to average 0.85 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:

CIBMTR Use Only

Sequence Number:

Date Received:

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Event date: ___ ___ ___ ___ - ___ ___ - ___ ___

Primary Disease for HCT / Cellular Therapy

Date of diagnosis of primary disease for HCT / cellular therapy: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

What was the primary disease for which the HCT / cellular therapy was performed?

 Acute myelogenous leukemia (AML or ANLL) (10) - Go to question 3

 Acute lymphoblastic leukemia (ALL) (20) - Go to question 90

 Acute leukemia of ambiguous lineage and other myeloid neoplasms (80) - Go to question 152

 Chronic myelogenous leukemia (CML) (40) - Go to question 156

 Myelodysplastic (MDS) / myeloproliferative (MPN) diseases (50) (Please classify all preleukemias)
(If recipient has transformed to AML, indicate AML as the primary disease) - Go to question 167

 Other leukemia (30) (includes CLL) - Go to question 261

 Hodgkin lymphoma (150) - Go to question 268

 Non-Hodgkin lymphoma (100) - Go to question 268

 Multiple myeloma / plasma cell disorder (PCD) (170) - Go to question 268

 Solid tumors (200) - Go to question 300

 Severe aplastic anemia (300) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease) - Go to question 302

 Inherited abnormalities of erythrocyte differentiation or function (310) - Go to question 304

 Disorders of the immune system (400) - Go to question 307

 Inherited abnormalities of platelets (500) - Go to question 310

 Inherited disorders of metabolism (520) - Go to question 312

 Histiocytic disorders (570) - Go to question 314

 Autoimmune diseases (600) - Go to question 316

 Other disease (900) - Go to question 324

Acute Myelogenous Leukemia (AML)

3. Specify the AML classification:

AML with recurrent genetic abnormalities

 AML with t(9;11) (p22.3;q23.3); MLLT3-KMT2A (5)

 AML with t(6;9) (p23;q34.1); DEK-NUP214 (6)

 AML with inv(3) (q21.3;q26.2) or t(3;3) (q21.3;q26.2); GATA2, MECOM (7)

 AML (megakaryoblastic) with t(1;22) (p13.3;q13.3); RBM15-MKL1 (8)

 AML with t(8;21); (q22; q22.1); RUNX1-RUNX1T1 (281)

 AML with inv(16)(p13.1;1q22) or t(16;16)(p13.1; q22); CBFB-MYH11 (282)

 APL with PML-RARA (283)

AML with BCR-ABL1 (provisional entity) (3)

AML with mutated NPM1 (4)

AML with biallelic mutations of CEBPA (297)

AML with mutated RUNX1 (provisional entity) (298)

 AML with 11q23 (MLL) abnormalities (i.e., t(4;11), t(6;11), t(9;11), t(11;19)) (284)

 AML with myelodysplasia – related changes (285)

 Therapy related AML (t-AML) (9)

AML, not otherwise specified

 AML, not otherwise specified (280)

 AML, minimally differentiated (286)

 AML without maturation (287)

 AML with maturation (288)

 Acute myelomonocytic leukemia (289)

 Acute monoblastic / acute monocytic leukemia (290)

 Acute erythroid leukemia (erythroid / myeloid and pure erythroleukemia) (291)

 Acute megakaryoblastic leukemia (292)

 Acute basophilic leukemia (293)

 Acute panmyelosis with myelofibrosis (294)

 Myeloid sarcoma (295)

Myeloid leukemia associated with Down syndrome (299)

3. Did AML transform from MDS or MPN?

 Yes – Also complete MDS Disease Classification questions

 No

3. Is the disease (AML) therapy related?

 Yes

 No

 Unknown

3. Did the recipient have a predisposing condition?

 Yes - Go to question 7

 No - Go to question 9

 Unknown - Go to question 9

3. Specify condition:

 Bloom syndrome - Go to question 9

 Down syndrome - Go to question 9

 Fanconi anemia - Also complete CIBMTR Form 2029 - Go to question 9

 Dyskeratosis congenita - Go to question 9

 Other condition - Go to question 8

3. Specify other condition: __________________________________________

Labs at diagnosis

3. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)

 Yes - Go to question 10

 No - Go to question 21

 Unknown - Go to question 21

3. Were cytogenetics tested via FISH?

 Yes – Go to question 11

 No - Go to question 15

3. Results of tests:

 Abnormalities identified – Go to question 12

 No abnormalities - Go to question 15

Specify cytogenetic abnormalities identified at diagnosis:

3. Specify number of distinct cytogenetic abnormalities:

One (1)

Two (2)

Three (3)

Four or more (4 or more)

3. Specify abnormalities (check all that apply)

 -5

 -7

 -17

 -18

 -X

 -Y

 +4

 +8

 +11

 +13

 +14

 +21

 +22

 t(3;3)

 t(6;9)

 t(8;21)

 t(9;11)

 t(9;22)

 t(15;17) and variants

 t(16;16)

 del(3q) / 3q–

 del(5q) / 5q–

 del(7q) / 7q–

 del(9q) / 9q–

 del(11q) / 11q–

 del(16q) / 16q–

 del(17q) / 17q–

 del(20q) / 20q–

 del(21q) / 21q–

 inv(3)

 inv(16)

 (11q23) any abnormality

 12p any abnormality

 Other abnormality - Go to question 14

3. Specify other abnormality: _____________________

3. Were cytogenetics tested via karyotyping?

 Yes – Go to question 16

 No - Go to question 20

3. Results of tests:

 Abnormalities identified – Go to question 17

 No evaluable metaphases - Go to question 21

 No abnormalities - Go to question 21

Specify cytogenetic abnormalities identified at diagnosis:

3. Specify number of distinct cytogenetic abnormalities:

One (1)

Two (2)

Three (3)

Four or more (4 or more)

3. Specify abnormalities: (check all that apply)

 -5

 -7

 -17

 -18

 -X

 -Y

 +4

 +8

 +11

 +13

 +14

 +21

 +22

 t(3;3)

 t(6;9)

 t(8;21)

 t(9;11)

 t(9;22)

 t(15;17) and variants

 t(16;16)

 del(3q) / 3q–

 del(5q) / 5q–

 del(7q) / 7q–

 del(9q) / 9q–

 del(11q) / 11q–

 del(16q) / 16q–

 del(17q) / 17q–

 del(20q) / 20q–

 del(21q) / 21q–

 inv(3)

 inv(16)

 (11q23) any abnormality

 12p any abnormality

 Other abnormality - Go to question 19

3. Specify other abnormality: _____________________

4. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

 Yes

 No

3. Were tests for molecular markers performed (e.g. PCR, NGS)? (at diagnosis)

 Yes – Go to question 22

 No – Go to question 34

 Unknown – Go to question 34

Specify molecular markers identified at diagnosis:

3. CEBPA

 Positive – Go to question 23

 Negative - Go to question 24

 Not done - Go to question 24

3. Specify CEBPA mutation

 Biallelic (homozygous)

 Monoallelic (heterozygous)

 Unknown

3. FLT3 – D835 point mutation

 Positive

 Negative

 Not done

3. FLT3 – ITD mutation

 Positive- Go to question 26

 Negative- Go to question 26

 Not done- Go to question 27

3. FLT3 – ITD allelic ratio

 Known - Go to question 27

 Unknown - Go to question 28

3. Specify FLT3 - ITD allelic ratio: ___ . ___

4. IDH1

 Positive

 Negative

 Not done

3. IDH2

 Positive

 Negative

 Not done

3. KIT

 Positive

 Negative

 Not done

3. NPM1

 Positive

 Negative

 Not done

3. Other molecular marker

 Positive- Go to question 33

 Negative- Go to question 33

 Not done- Go to question 34

3. Specify other molecular marker: _________________________________

Copy and complete questions 32-33 for multiple molecular markers

Labs between diagnosis and last evaluation:

3. Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)

 Yes - Go to question 35

 No - Go to question 46

 Unknown - Go to question 46

3. Were cytogenetics tested via FISH?

 Yes – Go to question 36

 No - Go to question 40

3. Results of tests:

 Abnormalities identified – Go to question 37

 No abnormalities - Go to question 40

Specify cytogenetic abnormalities identified between diagnosis and last evaluation:

3. Specify number of distinct cytogenetic abnormalities:

One (1)

Two (2)

Three (3)

Four or more (4 or more)

3. Specify abnormalities (check all that apply)

 -5

 -7

 -17

 -18

 -X

 -Y

 +4

 +8

 +11

 +13

 +14

 +21

 +22

 t(3;3)

 t(6;9)

 t(8;21)

 t(9;11)

 t(9;22)

 t(15;17) and variants

 t(16;16)

 del(3q) / 3q–

 del(5q) / 5q–

 del(7q) / 7q–

 del(9q) / 9q–

 del(11q) / 11q–

 del(16q) / 16q–

 del(17q) / 17q–

 del(20q) / 20q–

 del(21q) / 21q–

 inv(3)

 inv(16)

 (11q23) any abnormality

 12p any abnormality

 Other abnormality - Go to question 39

3. Specify other abnormality: _____________________

4. Were cytogenetics tested via karyotyping?

 Yes – Go to question 41

 No - Go to question 45

3. Results of tests:

 Abnormalities identified – Go to question 42

 No evaluable metaphases - Go to question 46

 No abnormalities - Go to question 46

Specify cytogenetic abnormalities identified between diagnosis and last evaluation:

3. Specify number of distinct cytogenetic abnormalities:

One (1)

Two (2)

Three (3)

Four or more (4 or more)

3. Specify abnormalities (check all that apply)

 -5

 -7

 -17

 -18

 -X

 -Y

 +4

 +8

 +11

 +13

 +14

 +21

 +22

 t(3;3)

 t(6;9)

 t(8;21)

 t(9;11)

 t(9;22)

 t(15;17) and variants

 t(16;16)

 del(3q) / 3q–

 del(5q) / 5q–

 del(7q) / 7q–

 del(9q) / 9q–

 del(11q) / 11q–

 del(16q) / 16q–

 del(17q) / 17q–

 del(20q) / 20q–

 del(21q) / 21q–

 inv(3)

 inv(16)

 (11q23) any abnormality

 12p any abnormality

 Other abnormality - Go to question 44

3. Specify other abnormality: _____________________

3. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

 Yes

 No

3. Were tests for molecular markers performed (e.g. PCR, NGS)? (between diagnosis and last evaluation)

 Yes – Go to question 47

 No – Go to question 59

 Unknown – Go to question 59

Specify molecular markers identified between diagnosis and last evaluation:

3. CEBPA

 Positive – Go to question 48

 Negative - Go to question 49

 Not done - Go to question 49

3. Specify CEBPA mutation

 Biallelic (homozygous)

 Monoallelic (heterozygous)

 Unknown

3. FLT3 – D835 point mutation

 Positive

 Negative

 Not done

3. FLT3 – ITD mutation

 Positive - Go to question 51

 Negative - Go to question 53

 Not done - Go to question 53

3. FLT3 – ITD allelic ratio

 Known - Go to question 52

 Unknown - Go to question 53

3. Specify FLT3 - ITD allelic ratio: ___ . ___

3. IDH1

 Positive

 Negative

 Not done

3. IDH2

 Positive

 Negative

 Not done

3. KIT

 Positive

 Negative

 Not done

3. NPM1

 Positive

 Negative

 Not done

3. Other molecular marker

 Positive- Go to question 58

 Negative- Go to question 58

 Not done- Go to question 59

3. Specify other molecular marker: _________________________________

Copy and complete questions 57-58 to report multiple other molecular markers

Labs at last evaluation:

3. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)

 Yes - Go to question 60

 No - Go to question 71

 Unknown - Go to question 71

3. Were cytogenetics tested via FISH?

 Yes – Go to question 61

 No - Go to question 65

3. Results of tests:

 Abnormalities identified – Go to question 62

 No abnormalities - Go to question 65

Specify cytogenetic abnormalities identified at last evaluation:

3. Specify number of distinct cytogenetic abnormalities:

One (1)

Two (2)

Three (3)

Four or more (4 or more)

3. Specify abnormalities (check all that apply)

 -5

 -7

 -17

 -18

 -X

 -Y

 +4

 +8

 +11

 +13

 +14

 +21

 +22

 t(3;3)

 t(6;9)

 t(8;21)

 t(9;11)

 t(9;22)

 t(15;17) and variants

 t(16;16)

 del(3q) / 3q–

 del(5q) / 5q–

 del(7q) / 7q–

 del(9q) / 9q–

 del(11q) / 11q–

 del(16q) / 16q–

 del(17q) / 17q–

 del(20q) / 20q–

 del(21q) / 21q–

 inv(3)

 inv(16)

 (11q23) any abnormality

 12p any abnormality

 Other abnormality - Go to question 64

3. Specify other abnormality: _____________________

3. Were cytogenetics tested via karyotyping?

 Yes – Go to question 66

 No - Go to question 71

3. Results of tests:

 Abnormalities identified – Go to question 67

 No evaluable metaphases - Go to question 71

 No abnormalities - Go to question 71

Specify cytogenetic abnormalities identified at last evaluation:

3. Specify number of distinct cytogenetic abnormalities:

One (1)

Two (2)

Three (3)

Four or more (4 or more)

3. Specify abnormalities (check all that apply)

 -5

 -7

 -17

 -18

 -X

 -Y

 +4

 +8

 +11

 +13

 +14

 +21

 +22

 t(3;3)

 t(6;9)

 t(8;21)

 t(9;11)

 t(9;22)

 t(15;17) and variants

 t(16;16)

 del(3q) / 3q–

 del(5q) / 5q–

 del(7q) / 7q–

 del(9q) / 9q–

 del(11q) / 11q–

 del(16q) / 16q–

 del(17q) / 17q–

 del(20q) / 20q–

 del(21q) / 21q–

 inv(3)

 inv(16)

 (11q23) any abnormality

 12p any abnormality

 Other abnormality - Go to question 69

3. Specify other abnormality: _____________________

4. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

 Yes

 No

3. Were tests for molecular markers performed (e.g. PCR, NGS)? (at last evaluation)

 Yes – Go to question 72

 No – Go to question 84

 Unknown – Go to question 84

Specify molecular markers identified at last evaluation:

3. CEBPA

 Positive – Go to question 73

 Negative - Go to question 74

 Not done - Go to question 74

3. Specify CEBPA mutation

 Biallelic (homozygous)

 Monoallelic (heterozygous)

 Unknown

3. FLT3 – D835 point mutation

 Positive

 Negative

 Not done

3. FLT3 – ITD mutation

 Positive - Go to question 76

 Negative - Go to question 78

 Not done - Go to question 78

3. FLT3 – ITD allelic ratio

 Known - Go to question 77

 Unknown - Go to question 78

3. Specify FLT3 - ITD allelic ratio: ___ . ___

3. IDH1

 Positive

 Negative

 Not done

3. IDH2

 Positive

 Negative

 Not done

3. KIT

 Positive

 Negative

 Not done

3. NPM1

 Positive

 Negative

 Not done

3. Other molecular marker

 Positive- Go to question 83

 Negative- Go to question 83

 Not done- Go to question 84

3. Specify other molecular marker: _________________________________

Copy and complete questions 82-83 to report multiple other molecular markers

CNS Leukemia

3. Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion?

 Yes

 No

 Unknown

Status at transplantation:

3. What was the disease status (based on hematological test results)?

 Primary induction failure – Go to question 89

 1st complete remission (no previous bone marrow or extramedullary relapse) (include CRi)– Go to question 86

 2nd complete remission – Go to question 86

 ≥ 3rd complete remission – Go to question 86

 1st relapse – Go to question 88

 2nd relapse – Go to question 88

 ≥ 3rd relapse – Go to question 88

 No treatment – Go to question 89

3. How many cycles of induction therapy were required to achieve 1st complete remission? (includes CRi)

1

2

≥ 3

3. Was the recipient in remission by flow cytometry?

Yes – Go to question 89

No – Go to question 89

Unknown – Go to question 89

Not applicable – Go to question 89

3. Date of most recent relapse: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

3. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line

YYYY MM DD

Acute Lymphoblastic Leukemia (ALL)

3. Specify ALL classification:

B-lymphoblastic leukemia / lymphoma

 B-lymphoblastic leukemia / lymphoma, NOS (B-cell ALL, NOS) (191)

 B-lymphoblastic leukemia / lymphoma with t(9;22)(q34.1;q11.2); BCR-ABL1 (192)

 B-lymphoblastic leukemia / lymphoma with t(v;11q23.3); KMT2A rearranged (193)

 B-lymphoblastic leukemia / lymphoma with t(1;19)(q23;p13.3); TCF3-PBX1 (194)

 B-lymphoblastic leukemia / lymphoma with t(12;21) (p13.2;q22.1); ETV6-RUNX1 (195)

 B-lymphoblastic leukemia / lymphoma with t(5;14) (q31.1;q32.3); IL3-IGH (81)

 B-lymphoblastic leukemia / lymphoma with Hyperdiploidy (51-65 chromosomes) (82)

 B-lymphoblastic leukemia / lymphoma with Hypodiploidy (<45 chromosomes) (83)

 B-lymphoblastic leukemia / lymphoma, BCR-ABL1-like (provisional entity) (94)

 B-lymphoblastic leukemia / lymphoma, with iAMP21 (provisional entity) (95)

T-cell lymphoblastic leukemia / lymphoma

 Early T-cell precursor lymphoblastic leukemia (provisional entity) (96)

Natural killer (NK)- cell lymphoblastic leukemia / lymphoma (provisional entity) (97)

3. Did the recipient have a predisposing condition?

 Yes - Go to question 92

 No - Go to question 94

 Unknown - Go to question 94

3. Specify condition:

Aplastic anemia - Go to question 94 Also complete CIBMTR Form 2028 — APL

Bloom syndrome - Go to question 94

Down syndrome - Go to question 94

Fanconi anemia - Go to question 924 Also complete CIBMTR Form 2029 — FAN

Other condition - Go to question 93

3. Specify other condition:

4. Were tyrosine kinase inhibitors given for therapy at any time prior to start of the preparative regimen / infusion? (e.g. imatinib mesylate, dasatinib, etc.)

 Yes

 No

Laboratory studies at diagnosis:

3. Were cytogenetics tested (karyotyping or FISH)? (at diagnosis)

 Yes - Go to question 96

 No - Go to question 106

 Unknown - Go to question 106

3. Were cytogenetics tested via FISH? (at diagnosis)

Yes - Go to question 97

 No - Go to question 101

3. Results of tests: (at diagnosis)

 Abnormalities identified - Go to question 98

 No abnormalities - Go to question 101

Specify cytogenetic abnormalities identified:

3. Specify number of distinct cytogenetic abnormalities:

 One (1)

 Two (2)

 Three (3)

 Four or more (4 or more)

3. Specify abnormalities: (check all that apply)

 –7

 +4

 +8

 +17

 +21

 t(1;19)

 t(2;8)

 t(4;11)

 t(5;14)

 t(8;14)

 t(8;22)

 t(9;22)

 t(10;14)

 t(11;14)

 t(12;21)

 del(6q) / 6q–

 del(9p) / 9p–

 del(12p) / 12p–

 add(14q)

 (11q23) any abnormality

 9p any abnormality

 12p any abnormality

 Hyperdiploid (> 50)

 Hypodiploid (< 45)

 iAMP21

 Other abnormality – Go to question 100

3. Specify other abnormality:

4. Were cytogenetics tested via karyotyping? (at diagnosis)

Yes - Go to question 102

No - Go to question 107

3. Results of tests: (at diagnosis)

 Abnormalities identified - Go to question 103

 No evaluable metaphases - Go to question 107

 No abnormalities - Go to question 107

Specify cytogenetic abnormalities identified:

3. Specify number of distinct cytogenetic abnormalities:

 One (1)

 Two (2)

 Three (3)

 Four or more (4 or more)

3. Specify abnormalities: (check all that apply)

 –7

 +4

 +8

 +17

 +21

 t(1;19)

 t(2;8)

 t(4;11)

 t(5;14)

 t(8;14)

 t(8;22)

 t(9;22)

 t(10;14)

 t(11;14)

 t(12;21)

 del(6q) / 6q–

 del(9p) / 9p–

 del(12p) / 12p–

 add(14q)

 (11q23) any abnormality

 9p any abnormality

 12p any abnormality

 Hyperdiploid (> 50)

 Hypodiploid (< 45)

 iAMP21

 Other abnormality – Go to question 105

3. Specify other abnormality: _________________________

4. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

 Yes

 No

3. Were tests for molecular markers performed (e.g. PCR, NGS)? (at diagnosis)

 Yes – Go to question 108

 No – Go to question 113

 Unknown – Go to question 113

Specify molecular markers identified at diagnosis:

3. BCR / ABL

 Positive

 Negative

 Not done

3. TEL-AML / AML1

 Positive

 Negative

 Not done

3. Other molecular marker

 Positive – Go to question 111

 Negative – Go to question 111

 Not done – Go to question 112

3. Specify other molecular marker:

Copy and complete questions 110-111 for additional molecular markers

Laboratory studies between diagnosis and last evaluation:

3. Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation)

 Yes - Go to question 113

 No - Go to question 124

 Unknown - Go to question 124

3. Were cytogenetics tested via FISH? (between diagnosis and the last evaluation)

Yes - Go to question 114

 No - Go to question 118

3. Results of tests: (between diagnosis and the last evaluation)

 Abnormalities identified - Go to question 115

 No abnormalities - Go to question 118

Specify cytogenetic abnormalities identified:

3. Specify number of distinct cytogenetic abnormalities:

 One (1)

 Two (2)

 Three (3)

 Four or more (4 or more)

3. Specify abnormalities: (check all that apply)

 –7

 +4

 +8

 +17

 +21

 t(1;19)

 t(2;8)

 t(4;11)

 t(5;14)

 t(8;14)

 t(8;22)

 t(9;22)

 t(10;14)

 t(11;14)

 t(12;21)

 del(6q) / 6q–

 del(9p) / 9p–

 del(12p) / 12p–

 add(14q)

 (11q23) any abnormality

 9p any abnormality

 12p any abnormality

 Hyperdiploid (> 50)

 Hypodiploid (< 45)

 iAMP21

 Other abnormality – Go to question 117

3. Specify other abnormality:

4. Were cytogenetics tested via karyotyping? (between diagnosis and the last evaluation)

Yes - Go to question 119

No - Go to question 124

3. Results of tests: (between diagnosis and the last evaluation)

 Abnormalities identified - Go to question 120

 No evaluable metaphases - Go to question 124

 No abnormalities - Go to question 124

Specify cytogenetic abnormalities identified:

3. Specify number of distinct cytogenetic abnormalities:

 One (1)

 Two (2)

 Three (3)

 Four or more (4 or more)

3. Specify abnormalities: (check all that apply)

 –7

 +4

 +8

 +17

 +21

 t(1;19)

 t(2;8)

 t(4;11)

 t(5;14)

 t(8;14)

 t(8;22)

 t(9;22)

 t(10;14)

 t(11;14)

 t(12;21)

 del(6q) / 6q–

 del(9p) / 9p–

 del(12p) / 12p–

 add(14q)

 (11q23) any abnormality

 9p any abnormality

 12p any abnormality

 Hyperdiploid (> 50)

 Hypodiploid (< 45)

 iAMP21

 Other abnormality – Go to question 122

3. Specify other abnormality:

4. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

 Yes

 No

3. Were tests for molecular markers performed (e.g. PCR, NGS)? (between diagnosis and last evaluation)

 Yes – Go to question 125

 No – Go to question 129

 Unknown – Go to question 129

Specify molecular markers identified between diagnosis and last evaluation:

3. BCR / ABL

 Positive

 Negative

 Not done

3. TEL-AML / AML1

 Positive

 Negative

 Not done

3. Other molecular marker

 Positive – Go to question 128

 Negative – Go to question 128

 Not done – Go to question 129

3. Specify other molecular marker:

Copy and complete questions 127-128 for additional molecular markers

Laboratory studies at last evaluation:

3. Were cytogenetics tested (karyotyping or FISH)? (at last evaluation)

 Yes - Go to question 130

 No - Go to question 141

 Unknown - Go to question 141

3. Were cytogenetics tested via FISH?

Yes - Go to question 131

 No - Go to question 135

3. Results of tests:

 Abnormalities identified - Go to question 132

 No abnormalities - Go to question 135

Specify cytogenetic abnormalities identified at last evaluation:

3. Specify number of distinct cytogenetic abnormalities:

 One (1)

 Two (2)

 Three (3)

 Four or more (4 or more)

3. Specify abnormalities: (check all that apply)

 –7

 +4

 +8

 +17

 +21

 t(1;19)

 t(2;8)

 t(4;11)

 t(5;14)

 t(8;14)

 t(8;22)

 t(9;22)

 t(10;14)

 t(11;14)

 t(12;21)

 del(6q) / 6q–

 del(9p) / 9p–

 del(12p) / 12p–

 add(14q)

 (11q23) any abnormality

 9p any abnormality

 12p any abnormality

 Hyperdiploid (> 50)

 Hypodiploid (< 45)

 iAMP21

 Other abnormality – Go to question 134

3. Specify other abnormality:

4. Were cytogenetics tested via karyotyping? (at last evaluation)

Yes - Go to question 136

No - Go to question 141

3. Results of tests:

 Abnormalities identified - Go to question 137

 No evaluable metaphases - Go to question 141

 No abnormalities - Go to question 141

Specify cytogenetic abnormalities identified at last evaluation:

3. Specify number of distinct cytogenetic abnormalities:

 One (1)

 Two (2)

 Three (3)

 Four or more (4 or more)

3. Specify abnormalities: (check all that apply)

 –7

 +4

 +8

 +17

 +21

 t(1;19)

 t(2;8)

 t(4;11)

 t(5;14)

 t(8;14)

 t(8;22)

 t(9;22)

 t(10;14)

 t(11;14)

 t(12;21)

 del(6q) / 6q–

 del(9p) / 9p–

 del(12p) / 12p–

 add(14q)

 (11q23) any abnormality

 9p any abnormality

 12p any abnormality

 Hyperdiploid (> 50)

 Hypodiploid (< 45)

 iAMP21

 Other abnormality – Go to question 139

3. Specify other abnormality:

4. Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report)

 Yes

 No

3. Were tests for molecular markers performed (e.g. PCR, NGS)? (at last evaluation)

 Yes – Go to question 142

 No – Go to question 146

 Unknown – Go to question 146

Specify molecular markers identified at last evaluation:

3. BCR / ABL

 Positive

 Negative

 Not done

3. TEL-AML / AML1

 Positive

 Negative

 Not done

3. Other molecular marker

 Positive – Go to question 145

 Negative – Go to question 145

 Not done – Go to question 146

3. Specify other molecular marker:

Copy and complete questions 144-145 for additional molecular markers

CNS Leukemia

3. Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion?

 Yes

 No

 Unknown

Status at transplantation:

3. What was the disease status (based on hematological test results)?

Primary induction failure – Go to question 151

1st complete remission (no previous marrow or extramedullary relapse)(include CRi) – Go to question 148

2nd complete remission – Go to question 148

≥ 3rd complete remission – Go to question 148

1st relapse – Go to question 150

2nd relapse – Go to question 150

≥ 3rd relapse – Go to question 150

No treatment – Go to question 151

3. How many cycles of induction therapy were required to achieve 1^st complete remission (include CRi)?

1

2

≥ 3

3. Was the recipient in remission by flow cytometry?

Yes – Go to question 151

No – Go to question 151

Unknown – Go to question 151

Not applicable – Go to question 151

3. Date of most recent relapse: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

3. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line

YYYY MM DD

Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms

3. Specify acute leukemias of ambiguous lineage and other myeloid neoplasm classification:

Blastic plasmacytoid dendritic cell neoplasm (296)– Go to question 154

 Acute undifferentiated leukemia (31) – Go to question 154

Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 (84) – Go to question 154

Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged (85) – Go to question 154

Mixed phenotype acute leukemia, B/myeloid, NOS (86) – Go to question 154

Mixed phenotype acute leukemia, T/myeloid, NOS (87) – Go to question 154

 Other acute leukemia of ambiguous lineage or myeloid neoplasm (88) - Go to question 153

3. Specify other acute leukemia of ambiguous lineage or myeloid neoplasm:

Status at transplantation:

3. What was the disease status (based on hematological test results)?

Primary induction failure

1st complete remission (no previous marrow or extramedullary relapse)

2nd complete remission

≥ 3rd complete remission

1st relapse

2nd relapse

≥3rd relapse

No treatment

3. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line

YYYY MM DD

Chronic Myelogenous Leukemia (CML)

3. Was therapy given prior to this HCT?

 Yes - Go to questions 157

 No - Go to question 163

3. Combination chemotherapy

 Yes

 No

3. Hydroxyurea (Droxia, Hydrea)

 Yes

 No

3. Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib)

 Yes

 No

3. Interferon-α (Intron, Roferon) (includes PEG)

 Yes

 No

3. Other therapy

 Yes - Go to question 162

 No - Go to question 163

3. Specify other therapy: ______________________________________

4. What was the disease status?

 Complete hematologic response (CHR) - Go to question 164

 Chronic phase – Go to question 164

 Accelerated phase - Go to question 165

 Blast phase - Go to question 165

3. Specify level of response

 No cytogenetic response (No CyR)

 Minimal cytogenetic response

 Minor cytogenetic response

 Partial cytogenetic response (PCyR)

 Complete cytogenetic response (CCyR)

 Major molecular remission (MMR)

 Complete molecular remission (CMR)

3. Number

 1st

 2nd

 3rd or higher

3. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line

YYYY MM DD

Myelodysplastic (MDS) / Myeloproliferative (MPN) Diseases

3. What was the MDS / MPN subtype at diagnosis? – If transformed to AML, indicate AML as primary disease; also complete AML Disease Classification questions

 Refractory cytopenia with unilineage dysplasia (RCUD) (includes refractory anemia (RA)) (51)

 Refractory anemia with ringed sideroblasts (RARS) (55)

 Refractory anemia with excess blasts-1 (RAEB-1) (61)

 Refractory anemia with excess blasts-2 (RAEB-2) (62)

 Refractory cytopenia with multilineage dysplasia (RCMD) (64)

 Childhood myelodysplastic syndrome (Refractory cytopenia of childhood (RCC)) (68)

 Myelodysplastic syndrome with isolated del(5q) (5q– syndrome) (66)

 Myelodysplastic syndrome (MDS), unclassifiable (50)

 Chronic neutrophilic leukemia (165)

 Chronic eosinophilic leukemia, NOS (166)

 Essential thrombocythemia (includes primary thrombocytosis, idiopathic thrombocytosis, hemorrhagic thrombocythemia) (58)

 Polycythemia vera (PCV) (57)

 Primary myelofibrosis (includes chronic idiopathic myelofibrosis (CIMF), angiogenic myeloid metaplasia (AMM), myelofibrosis/sclerosis with myeloid metaplasia (MMM), idiopathic myelofibrosis) (167)

 Mastocytosis

 Myeloproliferative neoplasm (MPN), unclassifiable (60)

 Myeloid/lymphoid neoplasms with PDGFRA rearrangement

 Myeloid/lymphoid neoplasms with PDGFRB rearrangement

 Myeloid/lymphoid neoplasms with FGFR1 rearrangement

 Myeloid/lymphoid neoplasms with PCM1-JAK2-

 Chronic myelomonocytic leukemia (CMMoL) (54)

 Juvenile myelomonocytic leukemia (JMML/JCML) (no evidence of Ph¹ or BCR/ABL) (36) – Go to question 212

 Atypical chronic myeloid leukemia (aCML), BCR-ABL1- – Go to question 265

 MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN–RS–T)

 Myelodysplastic / myeloproliferative neoplasm, unclassifiable (69)

3. Was the disease (MDS/MPN) therapy related?

 Yes

 No

 Unknown

3. Did the recipient have a predisposing condition?

 Yes – Go to question 168

 No – Go to question 170

 Unknown – Go to question 170

3. Specify condition:

 Aplastic anemia – Go to question 172

 Bloom syndrome – Go to question 172

 Down syndrome – Go to question 172

 Fanconi anemia – – Go to question 172

 Other condition – Go to question 171

3. Specify other condition:

Laboratory studies at diagnosis of MDS:

3. WBC

 Known

 Unknown

3. ___ ___ ___ ___ ___ ___ ● ___  x 10⁹/L (x 10³/mm³)

 x 10⁶/L

3. Hemoglobin

 Known

 Unknown

3. ___ ___ ___ ___ ● ___ ___  g/dL

 g/L

 mmol/L

3. Was RBC transfused ≤ 30 days before date of test?

 Yes

 No

3. Platelets

 Known

 Unknown

3. ___ ___ ___ ___ ___ ___ ___  x 10⁹/L (x 10³/mm³)

 x 10⁶/L

3. Were platelets transfused ≤ 7 days before date of test?

 Yes

 No

3. Neutrophils

 Known

 Unknown

3. ___ ___%

4. Blasts in bone marrow

 Known

 Unknown

3. ___ ___ ___ %

4. Were cytogenetics tested (karyotyping or FISH)?

 Yes – Go to question 185

 No – Go to question 212

 Unknown – Go to question 212

3. Results of tests:

 Abnormalities identified – Go to question 186

 No evaluable metaphases – Go to question 212

 No abnormalities – Go to question 212

Specify abnormalities identified at diagnosis:

3. Specify number of distinct cytogenetic abnormalities:

 One (1)

 Two (2)

 Three (3)

 Four or more (4 or more)

Monosomy

3. –5

 Yes

 No

3. –7

 Yes

 No

3. –13

 Yes

 No

3. –20

 Yes

 No

3. –Y

 Yes

 No

Trisomy

3. +8

 Yes

 No

3. +19

 Yes

 No

Translocation

3. t(1;3)

 Yes

 No

3. t(2;11)

 Yes

 No

3. t(3;3)

 Yes

 No

3. t(3;21)

 Yes

 No

3. t(6;9)

 Yes

 No

3. t(11;16)

 Yes

 No

Deletion

3. del(3q) / 3q-

 Yes

 No

3. del(5q) / 5q-

 Yes –

 No

3. del(7q) / 7q-

 Yes

 No

3. del(9q) / 9q-

 Yes

 No

3. del(11q) / 11q-

 Yes

 No

3. del(12p) / 12p-

 Yes

 No

3. del(13q) / 13q-

 Yes

 No

3. del(20q) / 20q-

 Yes

 No

Inversion

3. inv(3)

 Yes

 No

Other

3. i17q

 Yes

 No

3. Other abnormality

 Yes – Go to question 211

 No – Go to question 212

3. Specify other abnormality:

3. Did the recipient progress or transform to a different MDS / MPN subtype between diagnosis and the start of the preparative regimen?

 Yes – Go to question 213

 No – Go to question 216

3. Specify the MDS / MPN subtype after transformation:

 Refractory cytopenia with unilineage dysplasia (RCUD) (includes refractory anemia (RA)) (51) – Go to question 214

 Refractory anemia with ringed sideroblasts (RARS) (55) – Go to question 214

 Refractory anemia with excess blasts-1 (RAEB-1) (61) – Go to question 214

 Refractory anemia with excess blasts-2 (RAEB-2) (62) – Go to question 214

 Refractory cytopenia with multilineage dysplasia (RCMD) (64) – Go to question 214

 Childhood myelodysplastic syndrome (Refractory cytopenia of childhood (RCC)) (68) – Go to question 214

 Myelodysplastic syndrome with isolated del(5q) (5q– syndrome) (66) – Go to question 214

 Myelodysplastic syndrome (MDS), unclassifiable (50) – Go to question 214

 Chronic neutrophilic leukemia (165) – Go to question 214

 Chronic eosinophilic leukemia, NOS (166) – Go to question 214

 Essential thrombocythemia (includes primary thrombocytosis, idiopathic thrombocytosis, hemorrhagic thrombocythemia) (58) – Go to question 214

 Polycythemia vera (PCV) (57) – Go to question 214

 Primary myelofibrosis (includes chronic idiopathic myelofibrosis (CIMF), angiogenic myeloid metaplasia (AMM), myelofibrosis/sclerosis with myeloid metaplasia (MMM), idiopathic myelofibrosis) (167) – Go to question 214

 Mastocytosis

 Myeloproliferative neoplasm (MPN), unclassifiable (60) – Go to question 214

 Myeloid/lymphoid neoplasms with PDGFRA rearrangement

 Myeloid/lymphoid neoplasms with PDGFRB rearrangement

 Myeloid/lymphoid neoplasms with FGFR1 rearrangement

 Myeloid/lymphoid neoplasms with PCM1-JAK2-

 Chronic myelomonocytic leukemia (CMMoL) (54) – Go to question 214

 Atypical chronic myeloid leukemia (aCML), BCR-ABL1- – Go to question 265

 MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN–RS–T)

 Myelodysplastic / myeloproliferative neoplasm, unclassifiable (69) – Go to question 214

 Transformed to AML (70) – Go to question 215

3. Specify the date of the most recent transformation:___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 216

4. Date of MDS diagnosis: ___ ___ ___ ___ - ___ ___ - ___ ___ – Go to signature line

Laboratory studies at last evaluation prior to the start of the preparative regimen:

3. WBC

 Known

 Unknown

3. ___ ___ ___ ___ ___ ___ ● ___  x 10⁹/L (x 10³/mm³)

 x 10⁶/L

3. Hemoglobin

 Known

 Unknown

3. ___ ___ ___ ___ ● ___ ___  g/dL

 g/L

 mmol/L

3. Was RBC transfused ≤ 30 days before date of test?

 Yes

 No

3. Platelets

 Known

 Unknown

3. ___ ___ ___ ___ ___ ___ ___  x 10⁹/L (x 10³/mm³)

 x 10⁶/L

3. Were platelets transfused ≤ 7 days before date of test?

 Yes

 No

3. Neutrophils

 Known

 Unknown

3. ___ ___%

4. Blasts in bone marrow

 Known

 Unknown

3. ___ ___ ___ %

3. Were cytogenetics tested (karyotyping or FISH)?

 Yes – Go to question 229

 No – Go to question 256

 Unknown – Go to question 256

3. Results of tests:

 Abnormalities identified – Go to question 230

 No evaluable metaphases – Go to question 256

 No abnormalities – Go to question 256

Specify cytogenetic abnormalities identified at last evaluation prior to the start of the preparative regimen:

3. Specify number of distinct cytogenetic abnormalities:

 One (1)

 Two (2)

 Three (3)

 Four or more (4 or more)

Monosomy

3. –5

 Yes

 No

3. –7

 Yes

 No

3. –13

 Yes

 No

3. –20

 Yes

 No

3. –Y

 Yes

 No

Trisomy

3. +8

 Yes

 No

3. +19

 Yes

 No

Translocation

3. t(1;3)

 Yes

 No

3. t(2;11)

 Yes

 No

3. t(3;3)

 Yes

 No

3. t(3;21)

 Yes

 No

3. t(6;9)

 Yes

 No

3. t(11;16)

 Yes

 No

Deletion

3. del(3q) / 3q-

 Yes

 No

3. del(5q) / 5q-

 Yes

 No

3. del(7q) / 7q-

 Yes

 No

3. del(9q) / 9q-

 Yes

 No

3. del(11q) / 11q-

 Yes

 No

3. del(12p) / 12p-

 Yes

 No

3. del(13q) / 13q-

 Yes

 No

3. del(20q) / 20q-

 Yes

 No

Inversion

3. inv(3)

 Yes

 No

Other

3. i17q

 Yes

 No

3. Other abnormality

 Yes – Go to question 255

 No – Go to question 256

3. Specify other abnormality:

Status at transplantation:

3. What was the disease status?

 Complete remission (CR) – requires all of the following, maintained for ≥ 4 weeks: * bone marrow evaluation: < 5% myeloblasts with normal maturation of all cell lines * peripheral blood evaluation: hemoglobin ≥ 11 g/dL untransfused and without erythropoietin support; ANC ≥ 1000/mm³ without myeloid growth factor support; platelets ≥ 100 x 10⁹/L without thrombopoietic support; 0% blasts - Go to question 260

 Hematologic improvement (HI) – requires one measurement of the following, maintained for ≥ 8 weeks without ongoing cytotoxic therapy; specify which cell line was measured to determine HI response: * HI-E – hemoglobin increase of ≥ 1.5 g/dL untransfused; for RBC transfusions performed for Hgb ≤ 9.0, reduction in RBC units transfused in 8 weeks by ≥ 4 units compared to the pre-treatment transfusion number in 8 weeks * HI-P – for pre-treatment platelet count of > 20 x 10⁹/L, platelet absolute increase of ≥ 30 x 10⁹/L; for pre-treatment platelet count of < 20 x 10⁹/L, platelet absolute increase of ≥ 20 x 10⁹/L and ≥ 100% from pre-treatment level * HI-N – neutrophil count increase of ≥ 100% from pre-treatment level and an absolute increase of ≥ 500/mm³ - Go to question 257

 No response (NR) / stable disease (SD) – does not meet the criteria for at least HI, but no evidence of disease progression - Go to question 260

 Progression from hematologic improvement (Prog from HI) – requires at least one of the following, in the absence of another explanation (e.g., infection, bleeding, ongoing chemotherapy, etc.): * ≥ 50% reduction from maximum response levels in granulocytes or platelets * reduction in hemoglobin by ≥ 1.5 g/dL *transfusion dependence - Go to question 258

 Relapse from complete remission (Rel from CR) – requires at least one of the following: * return to pre-treatment bone marrow blast percentage * decrease of ≥ 50% from maximum response levels in granulocytes or platelets * transfusion dependence, or hemoglobin level ≥ 1.5 g/dL lower than prior to therapy - Go to question 259

 Not assessed - Go to signature line

3. Specify the cell line examined to determine HI status:

 HI-E – hemoglobin increase of ≥ 1.5 g/dL untransfused; for RBC transfusions performed for Hgb ≤ 9.0, reduction in RBC units transfused in 8 weeks by ≥ 4 units compared to the pre-treatment transfusion number in 8 weeks - Go to question 260

 HI-P – for pre-treatment platelet count of > 20 x 10⁹/L, platelet absolute increase of ≥ 30 x 10⁹/L; for pre-treatment platelet count of < 20 x 10⁹/L, platelet absolute increase of ≥ 20 x 10⁹/L and ≥ 100% from pre-treatment level – Go to question 260

 HI-N – neutrophil count increase of ≥ 100% from pre-treatment level and an absolute increase of ≥ 500/mm³ - Go to question 260

3. Date of progression: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 260

YYYY MM DD

3. Date of relapse: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 260

YYYY MM DD

3. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___- Go to signature line

YYYY MM DD

Other Leukemia (OL)

3. Specify the other leukemia classification:

 Chronic lymphocytic leukemia (CLL), NOS (34) - Go to question 263

 Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL) (71) - Go to question 263

 Hairy cell leukemia (35) - Go to question 266

 Hairy cell leukemia variant (75) - Go to question 266

 Monoclonal B-cell lymphocytosis (76) – Go to signature line

 Prolymphocytic leukemia (PLL), NOS (37) - Go to question 263

 PLL, B-cell (73) - Go to question 263

 PLL, T-cell (74) - Go to question 263

 Other leukemia, NOS (30) - Go to question 265

 Other leukemia (39) - Go to question 262

3. Specify other leukemia: – Go to question 265

4. Was any 17p abnormality detected?

 Yes – If disease classification is CLL, go to question 264. If PLL, go to question 266

 No

3. Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any time after CLL diagnosis?

 Yes – Go to question 271– Also complete NHL Disease Classification questions

 No – Go to question 266

Status at transplantation:

3. What was the disease status? (Atypical CML)

 Primary induction failure – Go to question 267

 1st complete remission (no previous bone marrow or extramedullary relapse) – Go to question 267

 2nd complete remission – Go to question 267

 ≥ 3rd complete remission – Go to question 267

 1st relapse – Go to question 267

 2nd relapse – Go to question 267

 ≥ 3rd relapse – Go to question 267

 No treatment – Go to signature line

3. What was the disease status? (CLL, PLL, Hairy cell leukemia)

 Complete remission (CR) – Go to question 267

 Partial remission (PR) – Go to question 267

 Stable disease (SD) – Go to question 267

 Progressive disease (Prog) – Go to question 267

 Untreated - Go to question 267

 Not assessed - Go to signature line

3. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line

YYYY MM DD

Hodgkin and Non-Hodgkin Lymphoma

268. Specify the lymphoma histology: (at transplant)

Hodgkin Lymphoma Codes

• Hodgkin lymphoma, not otherwise specified (150)

• Lymphocyte depleted (154)

• Lymphocyte-rich (151)

• Mixed cellularity (153)

• Nodular lymphocyte predominant Hodgkin lymphoma (155)

• Nodular sclerosis (152)

Non-Hodgkin Lymphoma Codes

B-cell Neoplasms

• ALK+ large B-cell lymphoma (1833)

• B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin lymphoma (149)

• Burkitt lymphoma (111)

• Burkitt-like lymphoma with 11q aberration (1834)

• Diffuse large B-cell Lymphoma (cell of origin unknown) (107)

• Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) – Go to question 270

• Diffuse, large B-cell lymphoma- Activated B-cell type (non-GCB) (1821) – Go to question 270

• DLBCL associated with chronic inflammation (1825)

• Duodenal-type follicular lymphoma (1815)

• EBV+ DLBCL, NOS (1823)

• EBV+ mucocutaneous ulcer (1824)

• Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT) (122)

• Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma) (102)

• Follicular, mixed, small cleaved and large cell (Grade II follicle center lymphoma) (103)

• Follicular, predominantly large cell (Grade IIIA follicle center lymphoma) (162)

• Follicular, predominantly large cell (Grade IIIB follicle center lymphoma) (163)

• Follicular, predominantly large cell (Grade IIIA vs IIIB not specified) (1814)

• Follicular (grade unknown) (164)

• HHV8+ DLBCL, NOS (1826)

• High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements (1831)

• High-grade B-cell lymphoma, NOS (1830)

• Intravascular large B-cell lymphoma (136)

• Large B-cell lymphoma with IRF4 rearrangement (1832)

• Lymphomatoid granulomatosis (1835)

• Mantle cell lymphoma (115)

• Nodal marginal zone B-cell lymphoma (± monocytoid B-cells) (123)

• Pediatric nodal marginal zone lymphoma (1813)

• Pediatric-type follicular lymphoma (1816)

• Plasmablastic lymphoma (1836)

• Primary cutaneous follicle center lymphoma (1817)

• Primary cutaneous DLBCL, leg type (1822)

• Primary diffuse, large B-cell lymphoma of the CNS (118)

• Primary effusion lymphoma (138)

• Primary mediastinal (thymic) large B-cell lymphoma (125)

• Splenic marginal zone B-cell lymphoma (124)

• Splenic B-cell lymphoma/leukemia, unclassifiable (1811)

• Splenic diffuse red pulp small B-cell lymphoma (1812)

• T-cell / histiocytic rich large B-cell lymphoma (120)

• Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173)

• Other B-cell lymphoma (129) – Go to question 269

T-cell and NK-cell Neoplasms

• Adult T-cell lymphoma / leukemia (HTLV1 associated) (134)

• Aggressive NK-cell leukemia (27)

• Angioimmunoblastic T-cell lymphoma (131)

• Anaplastic large-cell lymphoma (ALCL), ALK positive (143)

• Anaplastic large-cell lymphoma (ALCL), ALK negative (144)

• Breast implant–associated anaplastic large-cell lymphoma (1861)

• Chronic lymphoproliferative disorder of NK cells (1856)

• Extranodal NK / T-cell lymphoma, nasal type (137)

• Enteropathy-type T-cell lymphoma (133)

• Follicular T-cell lymphoma (1859)

• Hepatosplenic T-cell lymphoma (145)

• Indolent T-cell lymphoproliferative disorder of the GI tract (1858)

• Monomorphic epitheliotropic intestinal T-cell lymphoma (1857)

• Mycosis fungoides (141)

• Nodal peripheral T-cell lymphoma with TFH phenotype (1860)

• Peripheral T-cell lymphoma (PTCL), NOS (130)

• Primary cutaneous γδ T-cell lymphoma (1851)

• Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1852)

• Primary cutaneous acral CD8+ T-cell lymphoma (1853)

• Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (1854)

• Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell lymphoma (C-ALCL), lymphoid papulosis] (147)

• Sezary syndrome (142)

• Subcutaneous panniculitis-like T-cell lymphoma (146)

• Systemic EBV+ T-cell lymphoma of childhood (1855)

• T-cell large granular lymphocytic leukemia (126)

• Other T-cell / NK-cell lymphoma (139) Go to question 269

Posttransplant lymphoproliferative disorders (PTLD)

• Classical Hodgkin lymphoma PTLD (1876)

• Florid follicular hyperplasia PTLD (1873)

• Infectious mononucleosis PTLD (1872)

• Monomorphic PTLD (B- and T-/NK-cell types) (1875)

• Plasmacytic hyperplasia PTLD (1871)

• Polymorphic PTLD (1874)

268. Specify other lymphoma histology: ______________________ – Go to question 271

268. Assignment of DLBCL (germinal center B-cell type vs. Activated B-cell type) subtype was based on:

Immunohistochemistry (e.g. Han’s algorithm)

Gene expression profile

Unknown method

268. Is the lymphoma histology reported at transplant a transformation from CLL?

 Yes – Go to question 272

 No - Go to question 273

268. Was any 17p abnormality detected?

 Yes– Go to question 277

 No– Go to question 277

268. Is the lymphoma histology reported at transplant a transformation from a different lymphoma histology? (Not CLL)

 Yes – Go to question 274

 No – Go to question 277

268. Specify the original lymphoma histology: (prior to transformation) same option list as Q268

269. Specify other lymphoma histology:________________

270. Date of original lymphoma diagnosis:___ ___ ___ ___ - ___ ___ - ___ ___ (report the date of diagnosis of original lymphoma subtype)

268. Was a PET (or PET/CT) scan performed? (at last evaluation prior to the start of the preparative regimen / infusion)

Yes – Go to question 278

No – Go to question 283

268. Was the PET (or PET/CT) scan positive for lymphoma involvement at any disease site?

Yes

No

268. Date of PET scan

Known– Go to question 280

Unknown – Go to question 281

268. Date of PET (or PET/CT) scan: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

268. Deauville (five-point) score of the PET (or PET/CT) scan

Known – Go to question 282

Unknown – Go to question 283

268. Scale

 1- no uptake or no residual uptake

 2- slight uptake, but below blood pool (mediastinum)

 3- uptake above mediastinal, but below or equal to uptake in the liver

 4- uptake slightly to moderately higher than liver

 5- markedly increased uptake or any new lesion

Status at transplantation / infusion:

268. What was the disease status?

Disease untreated– Go to question 285

PIF res - Primary induction failure – resistant: NEVER in COMPLETE remission but with stable or progressive disease on treatment. – Go to question 284

 PIF sen / PR1 - Primary induction failure – sensitive: NEVER in COMPLETE remission but with partial remission on treatment. – Go to question 284

PIF unk - Primary induction failure – sensitivity unknown– Go to question 284

CR1 - 1^st complete remission: no bone marrow or extramedullary relapse prior to transplant– Go to question 284

CR2 - 2^nd complete remission– Go to question 284

CR3+ - 3^rd or subsequent complete remission– Go to question 284

REL1 unt - 1^st relapse – untreated; includes either bone marrow or extramedullary relapse– Go to question 284

REL1 res - 1^st relapse – resistant: stable or progressive disease with treatment– Go to question 284

REL1 sen - 1^st relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2) – Go to question 284

REL1 unk - 1^st relapse – sensitivity unknown– Go to question 284

REL2 unt - 2^nd relapse – untreated: includes either bone marrow or extramedullary relapse– Go to question 284

REL2 res - 2^nd relapse – resistant: stable or progressive disease with treatment– Go to question 284

REL2 sen - 2^nd relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)– Go to question 284

REL2 unk - 2^nd relapse – sensitivity unknown– Go to question 284

REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse– Go to question 284

REL3+ res - 3^rd or subsequent relapse – resistant: stable or progressive disease with treatment– Go to question 284

REL3+ sen - 3^rd or subsequent relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+)– Go to question 284

REL3+ unk - 3^rd relapse or greater – sensitivity unknown– Go to question 284

268. Total number of lines of therapy received: (at any time between diagnosis and HCT / infusion)

1 line

2 lines

3+ lines

268. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line

Multiple Myeloma / Plasma Cell Disorder (PCD)

287. Specify the multiple myeloma/plasma cell disorder (PCD) classification:

 Multiple myeloma-lgG (181) - Go to questions 289

 Multiple myeloma-lgA (182) - Go to questions 289

 Multiple myeloma-lgD (183) - Go to questions 289

 Multiple myeloma-lgE (184) - Go to questions 289

 Multiple myeloma-lgM (not Waldenstrom macroglobulinemia) (185) - Go to questions 289

 Multiple myeloma-light chain only (186) - Go to questions 289

 Multiple myeloma-non-secretory (187) - Go to questions 290

 Plasma cell leukemia (172) - Go to question 295

 Solitary plasmacytoma (no evidence of myeloma) (175) - Go to question 295

 Amyloidosis (174) - Go to question 295

 Osteosclerotic myeloma / POEMS syndrome (176) - Go to questions 295

 Light chain deposition disease (177) - Go to questions 295

 Other plasma cell disorder (179) - Go to question 288

287. Specify other plasma cell disorder: _____________________________ - Go to question 295

288. Light chain

 kappa

 lambda

287. What was the Durie-Salmon staging (at diagnosis)?

 Stage I (All of the following: Hgb > 10g/dL; serum calcium normal or <10.5 mg/dL; bone x-ray normal bone structure (scale 0), or solitary bone plasmacytoma only; low M-component production rates IgG < 5g/dL, IgA < 3g/dL; urine light chain M-component on electrophoresis <4g/24h) – Go to questions 291

 Stage II (Fitting neither Stage I or Stage III) – Go to questions 291

 Stage III (One of more of the following: Hgb < 8.5 g/dL; serum calcium > 12 mg/dL; advanced lytic bone lesions (scale 3); high M-component production rates IgG >7g/dL, IgA > 5g/dL; Bence Jones protein >12g/24h) – Go to questions 291

 Unknown – Go to questions 292

287. What was the Durie-Salmon sub classification (at diagnosis)?

 A - relatively normal renal function (serum creatinine < 2.0 mg/dL)

 B - abnormal renal function (serum creatinine ≥ 2.0 mg/dL)

I.S.S.:

287. Serum β2-microglobulin: ___ ___ ___ ● ___ ___ ___  μg/dL

 mg/L

 nmol/L

287. Serum albumin: ___ ___ ● ___  g/dL

 g/L

287. Stage

 1 (β₂-mic < 3.5, S. albumin ≥ 3.5)

 2 (not fitting stage 1 or 3)

 3 (β₂-mic ≥ 5.5; S. albumin —)

287. Were cytogenetics tested (karyotyping or FISH)?

Yes – Go to questions 296

No – Go to question 317

Unknown – Go to question 317

287. Results of tests:

Abnormalities identified – Go to question 297

No evaluable metaphases – Go to question 317

No abnormalities – Go to question 317

Specify cytogenetic abnormalities identified at any time prior to the start of the preparative regimen:

Trisomy

287. +3

Yes

No

287. +5

Yes

No

287. +7

Yes

No

287. +9

Yes

No

287. +11

Yes

No

287. +15

Yes

No

287. +19

Yes

No

Translocation

287. t(4;14)

Yes

No

287. t(6;14)

Yes

No

287. t(11;14)

Yes

No

287. t(14;16)

Yes

No

287. t(14;20)

Yes

No

Deletion

287. del (13)/13q-

Yes

No

287. del (17)/17p-

Yes

No

Other

287. Hyperdiploid (>50)

Yes

No

287. Hypodiploid (<46)

Yes

No

287. Any abnormality at 1q

Yes

No

287. Any abnormality at 1p

Yes

No

287. Other abnormality

Yes

No

287. Specify other abnormality:______________________________________________

Status at transplantation:

287. What was the disease status?

 Stringent complete remission (sCR). - CR as defined, plus: normal free light chain ratio, and absence of clonal cells in the bone marrow by immunohistochemistry or immunofluorescence (confirmation with repeat bone marrow biopsy not needed). (Presence and/or absence of clonal cells is based upon the κ/λ ratio. An abnormal κ/λ ratio by immunohistochemistry and/or immunofluorescence requires a minimum of 100 plasma cells for analysis. An abnormal ratio reflecting the presence of an abnormal clone is κ/λ of > 4:1 or < 1:2.) sCR requires two consecutive assessments made at any time before the institution of any new therapy, and no known evidence of progressive or new bone lesions if radiographic studies were performed; radiographic studies are not required to satisfy sCR requirements. - Go to question 318

 Complete remission (CR) — negative immunofixation on serum and urine samples, and disappearance of any soft tissue plasmacytomas, and < 5% plasma cells in the bone marrow (confirmation with repeat bone marrow biopsy not needed). CR requires two consecutive assessments made at any time before the institution of any new therapy, and no known evidence of progressive or new bone lesions if radiographic studies were performed; radiographic studies are not required to satisfy CR requirements. - Go to question 318

 Near complete remission (nCR) — serum and urine M-protein detectable by immunoelectrophoresis (IFE), but not on electrophoresis (negative SPEP & UPEP); < 5% plasma cells in bone marrow. nCR requires two consecutive assessments made at any time before the initiation of any new therapy, and no known evidence of progressive or new bone lesions if radiographic studies were performed; radiographic studies are not required to satisfy nCR requirements. - Go to question 318

 Very good partial remission (VGPR ) — serum and urine M-protein detectable by immunofixation but not on electrophoresis, or ≥ 90% reduction in serum M-protein and urine M-protein level < 100 mg/24 hours. VGPR requires two consecutive assessments made at any time before the institution of any new therapy, and no known evidence of progressive or new bone lesions if radiographic studies were performed; radiographic studies are not required to satisfy VGPR requirements. - Go to question 318

 Partial remission (PR) — ≥ 50% reduction in serum M-protein, and reduction in 24-hour urinary M-protein by ≥ 90% or to < 200 mg/24 hours. If the serum and urine M-protein are unmeasurable (i.e., do not meet any of the following criteria: • serum M-protein ≥ 1 g/dL. Urine M-protein ≥ 200 mg/24 hours • serum free light chain assay shows involved level ≥ 10 mg/dL, provided serum free light chain ratio is abnormal), a ≥ 50% decrease in the difference between involved and uninvolved free light chain levels is required in place of the M-protein criteria. If serum and urine M-protein are unmeasurable, and serum free light assay is also unmeasurable, a ≥ 50% reduction in plasma cells is required in place of M-protein, provided the baseline bone marrow plasma cell percentage was ≥ 30%. In addition to the above listed criteria, a ≥ 50% reduction in the size of soft tissue plasmacytomas is also required, if present at baseline. PR requires two consecutive assessments made at any time before the institution of any new therapy, and no known evidence of progressive or new bone lesions if radiographic studies were performed; radiographic studies are not required to satisfy PR requirements. - Go to question 318

 Stable disease (SD) — not meeting the criteria for CR, VGPR, PR or PD. SD requires two consecutive assessments made at any time before the institution of any new therapy, and no known evidence of progressive or new bone lesions if radiographic studies were performed; radiographic studies are not required to satisfy SD requirements. - Go to question 318

 Progressive disease (PD) — requires any one or more of the following: Increase of ≥ 25% from baseline in: serum M-component and/or (absolute increase ≥ 0.5 g/dL) (for progressive disease, serum M-component increases of ≥ 1 g/dL are sufficient to define relapse if the starting M-component is ≥ 5 g/dL). Urine M-component and/or (absolute increase ≥ 200 mg/24 hours) for recipients without measurable serum and urine M-protein levels: the difference between involved and uninvolved free light chain levels (absolute increase > 10 mg/dL). Bone marrow plasma cell percentage (absolute percentage ≥ 10%) (relapse from CR has a 5% cutoff vs. 10% for other categories of relapse) definite development of new bone lesions or soft tissue plasmacytomas, or definite increase in the size of any existing bone lesions or soft tissue plasmacytomas. Development of hypercalcemia (corrected serum calcium > 11.5 mg/dL or 2.65 mmol) that can be attributed solely to the plasma cell proliferative disorder PD requires two consecutive assessments made at any time before classification as disease progression, and/or the institution of any new therapy - Go to question 318

 Relapse from CR (Rel) (untreated) — requires one or more of the following: reappearance of serum or urine M-protein by immunofixation or electrophoresis development of ≥ 5% plasma cells in the bone marrow (relapse from CR has a 5% cutoff vs. 10% for other categories of relapse) appearance of any other sign of progression (e.g., new plasmacytoma, lytic bone lesion, hypercalcemia) Rel requires two consecutive assessments made at any time before classification as relapse, and/or the institution of any new therapy. – Go to question 318

 Unknown – Go to signature line

 Not applicable (Amyloidosis with no evidence of myeloma) – Go to signature line

287. Date assessed: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to signature line

YYYY MM DD

Solid Tumors

287. Specify the solid tumor classification:

Breast cancer (250)

Lung, small cell (202)

 Lung, non-small cell (203)

 Lung, not otherwise specified (230)

 Germ cell tumor, extragonadal (225)

 Testicular (210)

 Ovarian (epithelial) (214)

 Bone sarcoma (excluding Ewing family tumors) (273)

 Ewing family tumors of bone (including PNET) (275)

 Ewing family tumors, extraosseous (including PNET) (276)

 Fibrosarcoma (244)

 Hemangiosarcoma (246)

 Leiomyosarcoma (242)

 Liposarcoma (243)

 Lymphangio sarcoma (247)

 Neurogenic sarcoma (248)

 Rhabdomyosarcoma (232)

 Synovial sarcoma (245)

 Soft tissue sarcoma (excluding Ewing family tumors) (274)

 Central nervous system tumor, including CNS PNET (220)

 Medulloblastoma (226)

 Neuroblastoma (222)

 Head / neck (201)

 Mediastinal neoplasm (204)

 Colorectal (228)

 Gastric (229)

 Pancreatic (206)

 Hepatobiliary (207)

 Prostate (209)

 External genitalia (211)

 Cervical (212)

 Uterine (213)

 Vaginal (215)

 Melanoma (219)

 Wilm tumor (221)

 Retinoblastoma (223)

 Thymoma (231)

 Renal cell (208)

 Other solid tumor (269) – Go to question 320

 Solid tumor, not otherwise specified (200)

287. Specify other solid tumor: ______________________________- Go to signature line

Severe Aplastic Anemia

287. Specify the severe aplastic anemia classification:

 Acquired severe aplastic anemia, not otherwise specified (301)

 Acquired SAA secondary to hepatitis (302)

 Acquired SAA secondary to toxin / other drug (303)

 Acquired amegakaryocytosis (not congenital) (304)

 Acquired pure red cell aplasia (not congenital) (306)

 Dyskeratosis congenita (307)

 Other acquired cytopenic syndrome (309) – Go to question 322

287. Specify other acquired cytopenic syndrome: ________________________- Go to signature line

Inherited Abnormalities of Erythrocyte Differentiation or Function

287. Specify the inherited abnormalities of erythrocyte differentiation or function classification:

 Paroxysmal nocturnal hemoglobinuria (PNH) (56)

 Shwachman-Diamond (305)

 Diamond-Blackfan anemia (pure red cell aplasia) (312)

 Other constitutional anemia (319) – Go to question 324

 Fanconi anemia (311) (If the recipient developed MDS or AML, indicate MDS or AML as the primary disease).

 Sickle thalassemia (355)

 Sickle cell disease (356)

 Beta thalassemia major (357)

 Other hemoglobinopathy (359) – Go to question 325

287. Specify other constitutional anemia: ____________________________________

288. Specify other hemoglobinopathy:_______________________________

- Go to signature line

Disorders of the Immune System

287. Specify disorder of immune system classification:

 Adenosine deaminase (ADA) deficiency / severe combined immunodeficiency (SCID) (401)

 Absence of T and B cells SCID (402)

 Absence of T, normal B cell SCID (403)

 Omenn syndrome (404)

 Reticular dysgenesis (405)

 Bare lymphocyte syndrome (406)

 Other SCID (419) – Go to question 327

 SCID, not otherwise specified (410)

 Ataxia telangiectasia (451)

 HIV infection (452)

 DiGeorge anomaly (454)

 Common variable immunodeficiency (457)

 Leukocyte adhesion deficiencies, including GP180, CD-18, LFA and WBC adhesion deficiencies (459)

 Kostmann agranulocytosis (congenital neutropenia) (460)

 Neutrophil actin deficiency (461)

 Cartilage-hair hypoplasia (462)

 CD40 ligand deficiency (464)

 Other immunodeficiencies (479) – Go to question 328

 Immune deficiency, not otherwise specified (400)

 Chediak-Higashi syndrome (456)

 Griscelli syndrome type 2 (465)

 Hermansky-Pudlak syndrome type 2 (466)

 Chronic granulomatous disease (455)

 Wiskott-Aldrich syndrome (453)

 X-linked lymphoproliferative syndrome (458)

287. Specify other SCID: ____________________________- Go to signature line

288. Specify other immunodeficiency: ____________________________- Go to signature line

Inherited Abnormalities of Platelets

287. Specify inherited abnormalities of platelets classification:

 Congenital amegakaryocytosis / congenital thrombocytopenia (501)

 Glanzmann thrombasthenia (502)

 Other inherited platelet abnormality (509) – Go to question 330

287. Specify other inherited platelet abnormality: __________________________- Go to signature line

Inherited Disorders of Metabolism

287. Specify inherited disorders of metabolism classification:

 Osteopetrosis (malignant infantile osteopetrosis) (521)

Leukodystrophies

 Metachromatic leukodystrophy (MLD) (542)

 Adrenoleukodystrophy (ALD) (543)

 Krabbe disease (globoid leukodystrophy) (544)

 Lesch-Nyhan (HGPRT deficiency) (522)

 Neuronal ceroid lipofuscinosis (Batten disease) (523)

Mucopolysaccharidoses

 Hurler syndrome (IH) (531)

 Scheie syndrome (IS) (532)

 Hunter syndrome (II) (533)

 Sanfilippo (III) (534)

 Morquio (IV) (535)

 Maroteaux-Lamy (VI) (536)

 β-glucuronidase deficiency (VII) (537)

 Mucopolysaccharidosis (V) (538)

 Mucopolysaccharidosis, not otherwise specified (530)

Mucolipidoses

 Gaucher disease (541)

 Niemann-Pick disease (545)

 I-cell disease (546)

 Wolman disease (547)

 Glucose storage disease (548)

 Mucolipidoses, not otherwise specified (540)

Polysaccharide hydrolase abnormalities

 Aspartyl glucosaminidase (561)

 Fucosidosis (562)

 Mannosidosis (563)

 Polysaccharide hydrolase abnormality, not otherwise specified (560)

 Other inherited metabolic disorder (529) – Go to question 332

 Inherited metabolic disorder, not otherwise specified (520)

287. Specify other inherited metabolic disorder: _______________________________- Go to signature line

Histiocytic disorders

287. Specify histiocytic disorder classification:

 Hemophagocytic lymphohistiocytosis (HLH) (571)

 Langerhans cell histiocytosis (histiocytosis-X) (572)

 Hemophagocytosis (reactive or viral associated) (573)

 Malignant histiocytosis (574)

 Other histiocytic disorder (579) – Go to question 334

 Histiocytic disorder, not otherwise specified (570)

287. Specify other histiocytic disorder: ____________________________________- Go to signature line

Autoimmune Diseases

287. Specify autoimmune disease classification:

Arthritis

 Rheumatoid arthritis (603)

 Psoriatic arthritis / psoriasis (604)

 Juvenile idiopathic arthritis (JIA): systemic (Stills disease) (640)

 Juvenile idiopathic arthritis (JIA): oligoarticular (641)

 Juvenile idiopathic arthritis (JIA): polyarticular (642)

 Juvenile idiopathic arthritis (JIA): other (643) Go to question 337

 Other arthritis (633) – Go to question 336

Multiple sclerosis

 Multiple sclerosis (602)

Connective tissue diseases

 Systemic sclerosis (scleroderma) (607)

 Systemic lupus erythematosis (SLE) (605)

 Sjögren syndrome (608)

 Polymyositis / dermatomyositis (606)

 Antiphospholipid syndrome (614)

 Other connective tissue disease (634) – Go to question 338

Vasculitis

 Wegener granulomatosis (610)

 Classical polyarteritis nodosa (631)

 Microscopic polyarteritis nodosa (632)

 Churg-Strauss (635)

 Giant cell arteritis (636)

 Takayasu (637)

 Behcet syndrome (638)

 Overlap necrotizing arteritis (639)

 Other vasculitis (611) – Go to question 339

Other neurological autoimmune diseases

 Myasthenia gravis (601)

 Other autoimmune neurological disorder (644) – Go to question 340

Hematological autoimmune diseases

 Idiopathic thrombocytopenic purpura (ITP) (645)

 Hemolytic anemia (646)

 Evan syndrome (647)

 Other autoimmune cytopenia (648) – Go to question 341

Bowel diseases

 Crohn’s disease (649)

 Ulcerative colitis (650)

 Other autoimmune bowel disorder (651) – Go to question 342

287. Specify other arthritis:_________________________________

288. Specify other juvenile idiopathic arthritis (JIA):_________________________________

289. Specify other connective tissue disease:_________________________________

290. Specify other vasculitis:_________________________________

291. Specify other autoimmune neurological disorder:_________________________________

292. Specify other autoimmune cytopenia:_________________________________

293. Specify other autoimmune bowel disorder:_________________________________

- Go to signature line

Other Disease

287. Specify other disease: _________________________________________

First Name: ____________________________________________________________________________

Last Name:

E-mail address:

Date: ___ ___ ___ ___ — ___ ___ — ___ ___

YYYY MM DD

CIBMTR Form 2402 revision 2 (page 1 of 82) Draft 5/17/2017