Form 1 PandemicImpactTemplate.xlsx PRE-TED

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Overview

COVID-19 Pandemic Impact on HCT
Permissible Values

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Sheet 1: COVID-19 Pandemic Impact on HCT

Answer the following questions regarding changes in approach to HCT since March 1, 2020. This is required for ALL allogeneic HCTs and requested for autologous HCT. Submit spreadsheet via Service Now. Please use Category "COVID-19 (SARS-CoV2) Impact on Hematopoietic Cell Transplantation (HCT)"

Always Answer Examples of applicable impacts include changes to original HCT date, donor, product type, preparative regimen, and GVHD prophylaxis) - (Does not apply if infected by COVID-19 (SARS-CoV-2)) Options: Yes - continue with Q2. No - skip to Initials (Column Q).

Answer if Q1 = Yes (Date)

Select Yes to indicate the date in Q2 is estimated. Options: Yes

Options: Yes

Answer if Q1 = Yes and Donor was ALLO Options: Yes - continue with Q3. No - skip to Q5.

Answer if Q3 = Yes and Donor was ALLO Options: Unrelated donor Syngeneic (monozygotic twin) HLA-identical sibling (may include non-monozygotic twin) HLA-matched other relative (does NOT include a haplo-identical donor) HLA-mismatched relative

Answer if Q1 = Yes and Donor was ALLO Options: Yes No

Answer if Q5 = Yes Options: Bone marrow -continue with Q8 PBSC -continue with Q8 Single CBU -continue with Q8 Other product – Go to question 7

Answer if Q6 = Other (Free text)

Answer if Q5 = Yes Options: Yes No

Answer if Q1 = Yes and Donor was ALLO Options: Yes No

Answer if Q1 = Yes and Donor was ALLO Options: Yes No

Always Answer (Free text)

CCN

CRID

Infusion Date

Donor Type

1.Was the HCT impacted for a reason related to the COVID-19 (SARS-CoV-2) pandemic?

2.Original date of HCT:

Date estimated

No change to planned HCT date due to COVID-19 pandemic

3.Is the donor different than the originally intended donor?

4.Specify the originally intended donor:

5.Is the product type (bone marrow, PBSC, single cord blood unit) different than the originally intended product type?     If Yes, complete Q6. If no, skip to Q8.

6.Specify the originally intended product type:

7.Specify other product type:

8.Was the current product thawed from a cryopreserved state prior to infusion?

9.Did the preparative regimen change from the original plan?

10.Did the GVHD prophylaxis change from the original plan?

Initials of person completing record

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dd/mm/yyyy

ALLO_U

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#######

dd/mm/yyyy

ALLO_R

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#######

dd/mm/yyyy

ALLO_U

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#######

dd/mm/yyyy

AUTO

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#######

dd/mm/yyyy

ALLO_U

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#######

dd/mm/yyyy

AUTO

end of list

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Sheet 2: Permissible Values

Yes	Unrelated donor	Bone marrow
No	Syngeneic	PBSC
	HLA-identical sibling	Single cord blood unit
	HLA-matched other relative	Other product
	HLA-mismatched relative