1b Form 1 - 2400 R8

Pre-Transplant Essential Data

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

CIBMTR Use Only
Sequence Number:

Public Burden Statement: The purpose of the data collection is to fulfill the legislative mandate to
establish and maintain a standardized database of allogeneic marrow and cord blood transplants
performed in the United States or using a donor from the United States. The data collected also meets
the C.W. Bill Young Cell Transplantation Program requirements to provide relevant scientific information
not containing individually identifiable information available to the public in the form of summaries and
data sets. 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
information collection is 0915-0310 and it is valid until 10/31/2022. This information collection is voluntary
under The Stem Cell Therapeutic and Research Act of 2005, Public Law (Pub. L.) 109–129, as amended
by the Stem Cell Therapeutic and Research Reauthorization Act of 2010, Public Law 111–264 (the Act)
and the Stem Cell Therapeutic and Research Reauthorization Act of 2015, Public Law 114-104. Public
reporting burden for this collection of information is estimated to average 0.68 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 14N136B, Rockville, Maryland, 20857 or
paperwork@hrsa.gov.

Date Received:

Center Identification
CIBMTR Center Number: ___ ___ ___ ___ ___
EBMT Code (CIC): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Recipient Identification
CIBMTR Research ID (CRID): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Event date: __ __ __ __ / __ __ / __ __
YYYY

MM

DD

CIBMTR Form 2400 R8 (page 1 of 26). Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Recipient Information

Date of birth: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY

MM

DD

Sex


Male



Female

Ethnicity


Hispanic or Latino



Not Hispanic or Latino



Not applicable (not a resident of the USA)



Unknown

Race (check all that apply)


White – Go to question 5



Black or African American– Go to question 5



Asian– Go to question 5



American Indian or Alaska Native– Go to question 5



Native Hawaiian or Other Pacific Islander– Go to question 5



Not reported – Go to question 6



Unknown– Go to question 6
Race detail (check all that apply)


Eastern European



Mediterranean



Middle Eastern



North Coast of Africa



North American



Northern European



Western European



White Caribbean



White South or Central American



Other White



African



African American

CIBMTR Form 2400 R8 (page 2 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



Black Caribbean



Black South or Central American



Other Black



Alaskan Native or Aleut



North American Indian



American Indian, South or Central America



Caribbean Indian



South Asian



Filipino (Pilipino)



Japanese



Korean



Chinese



Vietnamese



Other Southeast Asian



Guamanian



Hawaiian



Samoan



Other Pacific Islander



Unknown

Country of primary residence


Afghanistan



Ghana



Palau



Aland Islands



Gibraltar



Palestine, State of



Albania



Greece



Panama



Algeria



Greenland



Papua New Guinea



American Samoa



Grenada



Paraguay



Andorra



Guadeloupe



Peru



Angola



Guam



Philippines



Anguilla



Guatemala



Pitcairn Islands



Antarctica



Guernsey



Poland



Antigua and Barbuda



Guinea



Portugal



Argentina



Guinea-Bissau



Puerto Rico



Armenia



Guyana



Qatar



Aruba



Haiti



Reunion



Australia





Romania



Austria

Heard Island and McDonald
Islands



Russia



Holy See

CIBMTR Form 2400 R8 (page 3 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



Azerbaijan



Honduras



Rwanda



Bahamas



Hong Kong



Saint Barthelemy



Bahrain



Hungary



Saint Helena



Bangladesh



Iceland



Saint Kitts and Nevis



Barbados



India



Saint Lucia



Belarus



Indonesia



Saint Martin, French



Belgium



Iran



Saint Pierre and Miquelon



Belize



Iraq





Benin



Ireland

Saint Vincent and the
Grenadines



Bermuda



Isle of Man



Samoa



Bhutan



Israel



San Marino



Bolivia



Italy



Sao Tome and Principe



Bonaire, Sint Eustatius and
Saba



Jamaica



Saudi Arabia



Japan



Senegal



Serbia



Seychelles



Sierra Leone



Singapore



Sint Maarten, Dutch



Slovak Republic



Slovenia



Solomon Islands



Somalia



South Africa



South Georgia and the South
Sandwich Islands



Bosnia and Herzegovina



Jersey



Botswana



Jordan



Bouvet Island



Kazakhstan



Brazil - Go to question 7



Kenya



British Indian Ocean Territory



Kiribati



British Virgin Islands



Kuwait



Brunei Darussalam



Kyrgyzstan



Bulgaria



Laos



Burkina Faso



Latvia



Burundi



Lebanon



Cambodia



Lesotho



Cameroon



Liberia



Canada - Go to question 8



South Korea



Libya



Cape Verde



South Sudan



Liechtenstein



Cayman Islands



Spain



Lithuania



Central African Republic



Sri Lanka



Luxembourg



Chad



Sudan



Macau



Chile



Suriname



Macedonia



China



Svalbard and Jan Mayen



Madagascar



Christmas Island



Swaziland



Malawi



Cocos (Keeling) Islands



Sweden



Malaysia



Colombia



Switzerland



Maldives



Syria

CIBMTR Form 2400 R8 (page 4 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



Comoros



Mali



Taiwan



Congo, Democratic Republic
of the



Malta



Tajikistan



Marshall Islands



Tanzania



Congo, Republic of the



Martinique



Thailand



Cook Islands



Mauritania



Timor-Leste



Costa Rica



Mauritius



Togo



Cote d’Ivoire



Mayotte



Tokelau



Croatia



Mexico



Tonga



Cuba



Micronesia



Trinidad and Tobago



Curacao



Moldova



Tunisia



Cyprus



Monaco



Turkey



Czech Republic



Mongolia



Turkmenistan



Denmark



Montenegro



Turks and Caicos Islands



Djibouti



Montserrat



Tuvalu



Dominica



Morocco



Uganda



Dominican Republic



Mozambique



Ukraine



Ecuador



Myanmar



United Arab Emirates



Egypt



Namibia





El Salvador



Nauru



Equatorial Guinea

United Kingdom (England,
Wales, Scotland, Northern
Ireland)



Nepal



Eritrea





Netherlands

United States - Go to
question 9



Estonia



Netherlands Antilles





Ethiopia



New Caledonia

United States Minor Outlying
Islands



Falkland Islands



New Zealand



United States Virgin Islands



Faroe Islands



Nicaragua



Uruguay



Fiji



Niger



Uzbekistan



Finland



Nigeria



Vanuatu



France



Niue



Venezuela



French Guiana



Norfolk Island



Vietnam



French Polynesia



North Korea



Wallis and Futuna Islands



French Southern Territories



Northern Mariana Islands



Western Sahara



Gabon



Norway



Yemen



Gambia



Oman



Zambia



Georgia



Pakistan



Zimbabwe



Germany

CIBMTR Form 2400 R8 (page 5 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

State of residence of recipient (for residents of Brazil) _________________________ - Go to question
10
 Acre

 Maranhão

 Rio de Janeiro

 Alagoas

 Mato Grosso

 Rio Grande do Norte

 Amapá

 Mato Grosso do Sul

 Rio Grande do Sul

 Amazonas

 Minas Gerais

 Rondônia

 Bahia

 Pará

 Roraima

 Ceará

 Paraíba

 Santa Catarina

 Distrito Federal

 Paraná

 São Paulo

 Espírito Santo

 Pernambuc

 Sergipe

 Goiás

 Piauí

 Tocantins

Province or territory of residence of recipient (for residents of Canada) ____________________- Go to
question 10
Provinces

Territories

 Alberta

 Nova Scotia

 Northwest Territories

 British Columbia

 Ontario

 Nunavut

 Manitoba

 Prince Edward Island

 Yukon

 New Brunswick

 Quebec

 Newfoundland and Labrador

 Saskatchewan

State of residence of recipient (for residents of USA) ______________________
☐ Alabama

☐ Kentucky

☐ North Dakota

☐ Arizona

☐ Maine

☐ Oklahoma

☐ Alaska

☐ Arkansas
☐ California
☐ Colorado

☐ Connecticut
☐ Delaware

☐ District of Columbia

☐ Louisiana
☐ Maryland

☐ Massachusetts
☐ Michigan

☐ Minnesota

☐ Mississippi
☐ Missouri

☐ Ohio

☐ Oregon

☐ Pennsylvania
☐ Rhode Island

☐ South Carolina
☐ South Dakota
☐ Tennessee

CIBMTR Form 2400 R8 (page 6 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

☐ Florida

☐ Montana

☐ Texas

☐ Hawaii

☐ Nevada

☐ Vermont

☐ Georgia

☐ Nebraska

☐ Idaho

☐ Utah

☐ New Hampshire

☐ Illinois

☐ New Jersey

☐ Indiana

☐ New Mexico

☐ Iowa

☐ Washington

☐ West Virginia

☐ New York

☐ Kansas

☐ Virginia

☐ Wisconsin

☐ North Carolina

☐ Wyoming

NMDP Recipient ID (RID): __ __ __ __ __ __ __
Zip or postal code for place of recipient’s residence (USA and Canada recipients only): ___ ___ ___ ___ ___
______ ___ ___ ___

Specify blood type (of recipient) (For allogeneic HCTs only)

 A
 B
 AB
 O
Specify Rh factor (of recipient) (For allogeneic HCTs only)

 Positive
 Negative
Has the recipient signed an IRB / ethics committee (or similar body) approved consent form to donate research
blood samples to the NMDP / CIBMTR? (For allogeneic HCTs only)


Yes (recipient consented) – Go to question 15



No (recipient declined) - Go to question 18



Not approached - Go to question 18



Not applicable (center not participating) - Go to question 18
Date form was signed: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY

MM

DD

Did the recipient submit a research sample to the NMDP/CIBMTR repository? (Related donors only)


Yes – Go to question 17

CIBMTR Form 2400 R8 (page 7 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___


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

No – Go to question 18
Research sample recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Is the recipient participating in a clinical trial? (clinical trial sponsors that use CIBMTR forms to capture outcomes
data)

 Yes - Go to question 19
 No – Go to question 24
Study Sponsor


BMT CTN – Go to question 21



RCI BMT – Go to question 21



PIDTC – Go to question 21



USIDNET – Go to question 22



COG – Go to question 22



Other sponsor – Go to question 20
Specify other sponsor: ________________________________ - Go to question 22
Study ID Number: _____________________
Subject ID: ______________________
Specify the ClinicalTrials.gov identification number: NCT __ __ __ __ __ __ __ __

Copy questions 19-23 to report participation in more than one study.
Hematopoietic Cellular Transplant (HCT) and Cellular Therapy

Is a subsequent HCT planned as part of the overall treatment protocol? (not as a reaction to post-HCT disease
assessment) (For autologous HCTs only)


Yes – Go to question 25



No – Go to question 26
Specify subsequent HCT planned


Autologous



Allogeneic

Has the recipient ever had a prior HCT?

 Yes – Go to question 27
 No – Go to question 38
CIBMTR Form 2400 R8 (page 8 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Specify the number of prior HCTs: ___ ___
Were all prior HCTs reported to the CIBMTR?


Yes – Go to question 33



No – Go to question 29



Unknown – Go to question 33

Copy and complete questions 29- 32 to report all prior HCTs that have not yet been reported to the
CIBMTR
Date of the prior HCT: ___ ___ ___ ___ — ___ ___ — ___ ___  Date estimated
YYYY

MM

DD

Was the prior HCT performed at a different institution?


Yes – Go to question 31



No – Go to question 32

Specify the institution that performed the last HCT
Name: _______________________________________________________________
City:__________________________________________________________________
State: _________________________________________________________________
Country: _______________________________________________________________
What was the HPC source for the prior HCT? (check all that apply)


Autologous



Allogeneic, unrelated



Allogeneic, related

Reason for current HCT


Graft failure / insufficient hematopoietic recovery – Go to question 34



Persistent primary disease– Go to question 38



Recurrent primary disease– Go to question 35



Planned subsequent HCT, per protocol– Go to question 38



New malignancy (including PTLD and EBV lymphoma) – Go to question 36



Insufficient chimerism– Go to question 38



Other– Go to question 37
Date of graft failure / rejection: ___ ___ ___ ___ — ___ ___ — ___ ___ – Go to question 38

CIBMTR Form 2400 R8 (page 9 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

MM

DD

Date of relapse: ___ ___ ___ ___ — ___ ___ — ___ ___ – Go to question 38
YYYY

MM

DD

Date of secondary malignancy: ___ ___ ___ ___ — ___ ___ — ___ ___ – Go to question 38
YYYY

MM

DD

Specify other reason: __________________________ - Go to question 38
Has the recipient ever had a prior cellular therapy? (do not include DLIs)

 Yes – Go to question 39
 No – Go to question 44


Unknown– Go to question 44
Were all prior cellular therapies reported to the CIBMTR?


Yes – Go to question 44



No – Go to question 40



Unknown– Go to question 44

Copy and complete questions 40-43 to report all prior cellular therapies that have not yet been
reported to the CIBMTR
Date of the prior cellular therapy: __ __ __ __ -- __ __ -- __ __
YYYY

MM

DD

Was the cellular therapy performed at a different institution?


Yes – Go to question 42



No – Go to question 43
Name: ___________________________________________________________________
City: ____________________________________________________________________
State: ___________________________________________________________________
Country: _________________________________________________________________

Specify the source(s) for the prior cellular therapy (check all that apply)


Autologous



Allogeneic, unrelated



Allogeneic, related

CIBMTR Form 2400 R8 (page 10 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Donor Information

Multiple donors?


Yes – Go to question 45



No - Go to question 46
Specify number of donors: ___ ___

To report more than one donor, copy questions 46-82 and complete for each donor.
Specify donor


Autologous



Allogeneic, related



Allogeneic, unrelated

Specify product type (check all that apply)


Bone marrow



PBSC



Single cord blood unit



Other product– Go to question 48
Specify other product: _______________________________________

Is the product genetically modified? If autologous, go to question 77. If allogeneic related, go to question 50.
If allogeneic unrelated, go to question 54.


Yes



No
Specify the related donor type


Syngeneic (monozygotic twin) – Go to question 55



HLA-identical sibling (may include non-monozygotic twin) – Go to question 55



HLA-matched other relative (does NOT include a haplo-identical donor) - Go to question 51



HLA-mismatched relative– Go to question 51
Specify the biological relationship of the donor to the recipient


Mother



Father



Child



Sibling

CIBMTR Form 2400 R8 (page 11 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



Fraternal twin



Maternal aunt



Maternal uncle



Maternal cousin



Paternal aunt



Paternal uncle



Paternal cousin



Grandparent



Grandchild



Other biological relative – Go to question 52
Specify other biological relative: _________________________– Go to question 53

Degree of mismatch (related donors only)


HLA-mismatched 1 allele– Go to question 55



HLA-mismatched >2 alleles (does include haplo-identical donor) – Go to question 55

Specify unrelated donor type


HLA matched unrelated



HLA mismatched unrelated

Did NMDP / Be the Match facilitate the procurement, collection, or transportation of the product?


Yes



No

Was this donor used for any prior HCTs? (for this recipient)


Yes



No

NMDP cord blood unit ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ – Go to question 72
Registry donor ID: (not applicable for related donors)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - Go to question 63
Non-NMDP cord blood unit ID: (include related and autologous CBUs)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ - Go to question 61
CIBMTR Form 2400 R8 (page 12 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Global Registration Identifier for Donors (GRID): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
__ __
NMDP donor, go to question 72
Non-NMDP unrelated donor, go to question 63
Is the CBU ID also the ISBT DIN number?


Yes – Go to question 63



No – Go to question 62



Unknown– Go to question 63
Specify the ISBT DIN number: ____________________________________

Registry or UCB Bank ID: ___ ___ ___ ___ - If ‘Other registry’ go to 64, otherwise go to question 65
Specify other Registry or UCB Bank: _______________________________ - Go to question 65
Donor date of birth


Known – Go to question 66



Unknown – Go to question 67
Donor date of birth: ___ ___ ___ ___ — ___ ___ — ___ ___ - Go to question 69
YYYY

MM

DD

Donor age


Known – Go to question 68



Unknown – Go to question 69
Donor age: ___ ___

 Months (use only if less than 1 year old)
 Years

Donor sex


Male



Female

Specify blood type (donor) (non-NMDP allogeneic donors only)


A



B



AB



O

CIBMTR Form 2400 R8 (page 13 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Specify Rh factor (donor) (non-NMDP allogeneic donors only)


Positive



Negative

Donor CMV-antibodies (IgG or Total) (Allogeneic HCTs only)


Reactive



Non-reactive



Indeterminate



Not done



Not applicable (cord blood unit)

Has the donor signed an IRB / ethics committee (or similar body) approved consent form to donate research blood
samples to the NMDP / CIBMTR? (Related donors only)


Yes (donor consented) – Go to question 74



No (donor declined) - Go to question 77



Not approached - Go to question 77



Not applicable (center not participating) - Go to question 77
Date form was signed: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY

MM

DD

Did the donor submit a research sample to the NMDP/CIBMTR repository? (Related donors only)


Yes – Go to question 76



No – Go to question 77
Research sample donor ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Specify number of products infused from this donor: ___ ___
Specify the number of these products intended to achieve hematopoietic engraftment: ___ ___
Questions 79-80 are for autologous HCT recipients only.
What agents were used to mobilize the autologous recipient for this HCT? (check all that apply)


G-CSF (filgrastim, Neupogen)



Pegylated G-CSF (pegfilgrastim, Neulasta)



Plerixafor (Mozobil)



Combined with chemotherapy

CIBMTR Form 2400 R8 (page 14 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___


Anti-CD20 (rituximab, Rituxan)



Other agent– Go to question 80

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

Specify other agent: ___________________
Name of product: (gene therapy recipients)
 Other name
Specify other name: ____________________

To report more than one donor, copy questions 46-82 and complete for each donor.
Clinical Status of Recipient Prior to the Preparative Regimen (Conditioning)

What scale was used to determine the recipient’s functional status?


Karnofsky (recipient age ≥ 16 years) – Go to question 84



Lansky (recipient age ≥ 1 year and < 16 years) – Go to question 85

Performance score prior to the preparative regimen:
Karnofsky Scale (recipient age ≥ 16 years)


100 Normal; no complaints; no evidence of disease - Go to question 86



90 Able to carry on normal activity - Go to question 86



80 Normal activity with effort - Go to question 86



70 Cares for self; unable to carry on normal activity or to do active work - Go to question 86



60 Requires occasional assistance but is able to care for most needs - Go to question 86



50 Requires considerable assistance and frequent medical care - Go to question 86



40 Disabled; requires special care and assistance - Go to question 86



30 Severely disabled; hospitalization indicated, although death not imminent - Go to question 86



20 Very sick; hospitalization necessary - Go to question 86



10 Moribund; fatal process progressing rapidly - Go to question 86

Lansky Scale (recipient age ≥ 1 year and < 16 years)


100 Fully active



90 Minor restriction in physically strenuous play



80 Restricted in strenuous play, tires more easily, otherwise active



70 Both greater restrictions of, and less time spent in, active play

CIBMTR Form 2400 R8 (page 15 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



60 Ambulatory up to 50% of time, limited active play with assistance / supervision



50 Considerable assistance required for any active play; fully able to engage in quiet play



40 Able to initiate quiet activities



30 Needs considerable assistance for quiet activity



20 Limited to very passive activity initiated by others (e.g., TV)



10 Completely disabled, not even passive play

Recipient CMV-antibodies (IgG or Total)


Reactive



Non-reactive



Indeterminate



Not done

Comorbid Conditions

Has the patient been infected with COVID-19 (SARS-CoV-2) based on a positive test result at any time prior to
the start of the preparative regimen / infusion?


Yes – Go to question 88



No – Go to question 90
Did the patient require hospitalization for management of COVID-19 (SARS-CoV-2) infection?


Yes – Go to question 89



No – Go to question 90
Was mechanical ventilation used for COVID-19 (SARS-CoV-2) infection?


Yes



No

Is there a history of mechanical ventilation (excluding COVID-19 (SARS-CoV-2))?


Yes



No

Is there a history of invasive fungal infection?


Yes



No

Glomerular filtration rate (GFR) before start of preparative regimen (pediatric only)


Known- Go to question 93



Unknown- Go to question 94

CIBMTR Form 2400 R8 (page 16 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Glomerular filtration rate (GFR): __ __ __ mL/min/1.732
Does the recipient have known complex congenital heart disease? (corrected or uncorrected) (excluding simple
ASD, VSD, or PDA repair) (pediatric only)


Yes



No

Were there any co-existing diseases or organ impairment present according to the HCT comorbidity index (HCTCI)? (Source: Sorror, M. L. (2013). How I assess comorbidities before hematopoietic cell transplantation. Blood,
121(15), 2854-2863.)


Yes- Go to question 96



No- Go to question 102
Specify co-existing diseases or organ impairment (check all that apply)


Arrhythmia - Any history of atrial fibrillation or flutter, sick sinus syndrome, or ventricular
arrhythmias requiring treatment



Cardiac -Any history of coronary artery disease (one or more vessel-coronary artery stenosis
requiring medical treatment, stent, or bypass graft), congestive heart failure, myocardial
infarction, OR ejection fraction ≤ 50% on the most recent test



Cerebrovascular disease -Any history of transient ischemic attack, subarachnoid hemorrhage
or cerebral thrombosis, embolism, or hemorrhage



Diabetes -Requiring treatment with insulin or oral hypoglycemic drugs in the last 4 weeks but
not diet alone



Heart valve disease -At least a moderate to severe degree of valve stenosis or insufficiency as
determined by Echo; prosthetic mitral or aortic valve; or symptomatic mitral valve prolapse



Hepatic, mild - Bilirubin > upper limit of normal to 1.5 × upper limit of normal, or AST/ALT >
upper limit of normal to 2.5 × upper limit of normal at the time of transplant OR any history of
hepatitis B or hepatitis C infection



Hepatic, moderate/severe -Liver cirrhosis, bilirubin > 1.5 × upper limit of normal, or AST/ALT >
2.5 × upper limit of normal



Infection -Includes a documented infection, fever of unknown origin, or pulmonary nodules
suspicious for fungal pneumonia or a positive PPD test requiring prophylaxis against
tuberculosis. Patients must have started antimicrobial treatment before Day 0 with
continuation of antimicrobial treatment after Day 0



Inflammatory bowel disease -Any history of Crohn’s disease or ulcerative colitis requiring
treatment



Obesity -Patients older than 18 years with a body mass index (BMI) > 35 kg/m2 prior to the
start of conditioning or a BMI of the 95th percentile of higher for patients aged 18 years or
younger



Peptic ulcer -Any history of peptic (gastric or duodenal) ulcer confirmed by endoscopy or
radiologic diagnosis requiring treatment



Psychiatric disturbance -Presence of any mood (e.g., depression), anxiety, or other psychiatric
disorder (e.g. bipolar disorder or schizophrenia) requiring continuous treatment in the last 4
weeks

CIBMTR Form 2400 R8 (page 17 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



Pulmonary, moderate -Corrected diffusion capacity of carbon monoxide and/or FEV1 of 6680% or dyspnea on slight activity attributed to pulmonary disease at transplant



Pulmonary, severe -Corrected diffusion capacity of carbon monoxide and/or FEV1 of ≤ 65% or
dyspnea at rest attributed to pulmonary disease or the need for intermittent or continuous
oxygen during the 4 weeks prior to transplant



Renal, moderate / severe -Serum creatinine > 2 mg/dL or > 177 μmol/L; on dialysis during the 4
weeks prior to transplant; OR prior renal transplantation -go to question 97



Rheumatologic -Any history of a rheumatologic disease (e.g., systemic lupus erythematosis,
rheumatoid arthritis, polymyositis, mixed connective tissue disease, or polymyalgia
rheumatica, etc.) requiring treatment. (Do NOT include degenerative joint disease,
osteoarthritis)



Prior malignancy-Treated at any time point in the patient’s past history, other than the primary
disease for which this infusion is being performed -go to question 98
Was the recipient on dialysis immediately prior to start of preparative regimen?


Yes



No



Unknown

Specify prior malignancy (check all that apply)


Breast cancer



Central nervous system (CNS) malignancy (e.g., glioblastoma, astrocytoma)



Gastrointestinal malignancy (e.g., colon, rectum, stomach, pancreas, intestine, esophageal)



Genitourinary malignancy (e.g., kidney, bladder, ovary, testicle, genitalia, uterus, cervix,
prostate)



Leukemia (includes acute or chronic leukemia)



Lung cancer



Lymphoma (includes Hodgkin & non-Hodgkin lymphoma)



MDS / MPN



Melanoma



Multiple myeloma / plasma cell disorder (PCD)



Oropharyngeal cancer (e.g., tongue, buccal mucosa)



Sarcoma



Thyroid cancer



Other skin malignancy (basal cell, squamous)- go to question 99



Other hematologic malignancy -go to question 100



Other solid tumor -go to question 101
Specify other skin malignancy: (prior) _______________________________
Specify other hematologic malignancy: (prior) _____________________________

CIBMTR Form 2400 R8 (page 18 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Specify other solid tumor: (prior) _______________
Use results within 4 weeks prior to the start of the preparative regimen, report results from the test performed
closest to the start date. Biomarkers according to the augmented HCT comorbidity index. (Source: Biol Blood
Marrow Transplant. 2015 Aug; 21(8): 1418–1424)

Serum ferritin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date)


Known – Go to question 103



Unknown – Go to question 106
___ ___ ___ ___ ___ ng/mL (μg/L)

Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY

MM

DD

Upper limit of normal for your institution: ___ ___ ___ ___ ___
Serum albumin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date)


Known – Go to question 107



Unknown – Go to question 109
___ ___ ● ___

 g/dL

 g/L
Date sample collected: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY

MM

DD

Platelets (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date)


Known – Go to question 110



Unknown – Go to question 112
___ ___ ___ ___ ___ ___ ___

 x 109/L (x 103/mm3)
 x 106/L

Were platelets transfused < 7 days before date of test?


Yes



No



Unknown

CIBMTR Form 2400 R8 (page 19 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Did the recipient have a prior solid organ transplant?


Yes- Go to question 113



No- Go to question 116
Specify organ:


Bowel



Heart



Kidney(s)



Liver



Lung(s)



Pancreas



Other organ- Go to question 114
Specify other organ: _______________________________

Year of prior solid organ transplant: ___ ___ ___ ___
YYYY

Copy and complete questions 113-115 for each prior solid organ transplant
Pre-HCT Preparative Regimen (Conditioning)

Height at initiation of pre-HCT preparative regimen: ___ ___ ___

 inches
 centimeters

Actual weight at initiation of pre-HCT preparative regimen: ___ ___ ___ . ___

 pounds
 kilograms

Was a pre-HCT preparative regimen prescribed?


Yes – Go to question 119



No – Go to question 132
Classify the recipient’s prescribed preparative regimen (Allogeneic HCTs only)


Myeloablative



Non-myeloablative (NST)



Reduced intensity (RIC)

Was irradiation planned as part of the pre-HCT preparative regimen?


Yes – Go to question 121



No – Go to question 126

CIBMTR Form 2400 R8 (page 20 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

What was the prescribed radiation field?


Total body – Go to question 122



Total body by intensity-modulated radiation therapy (IMRT) – Go to question 122



Total lymphoid or nodal regions – Go to question 122



Thoracoabdominal region – Go to question 122

Total prescribed dose: (dose per fraction x total number of fractions) ___ ___ ___ ___ . ___  Gy

 cGy
Date started: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY

MM

DD

Was the radiation fractionated?


Yes – Go to question 125



No – Go to question 126
Total number of fractions: ___ ___

Indicate the total prescribed cumulative dose for the preparative regimen
Drug (drop down list)


Bendamustine



Busulfan



Carboplatin



Carmustine (BCNU)



CCNU (Lomustine)



Clofarabine (Clolar)



Cyclophosphamide (Cytoxan)



Cytarabine (Ara-C)



Etoposide (VP-16, VePesid)



Fludarabine



Gemcitabine



Ibritumomab tiuxetan (Zevalin)



Ifosfamide



Melphalan (L-Pam)



Methylprednisolone (Solu-Medrol)



Pentostatin



Propylene glycol-free melphalan (Evomela)

CIBMTR Form 2400 R8 (page 21 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



Rituximab (Rituxan)



Thiotepa



Tositumomab (Bexxar)



Treosulfan



Other drug -go to question 127
Specify other drug: ___________

Total prescribed dose: __ __ __ __ __. __  mg/m2
 mg/kg
 AUC (mg x h/L)
 AUC (µmol x min/L)
CSS (ng/mL)
Date started: ___ ___ ___ ___ — ___ ___ — ___ ___
YYYY

MM

DD

Specify administration (busulfan only)


Oral



IV



Both

Copy and complete question 126-130 to report each drug given for the preparative regimen
Additional Drugs Given in the Peri-Transplant Period

ALG, ALS, ATG, ATS


Yes – Go to question 132



No – Go to question 135
Total prescribed dose: ___ ___ ___ ___ ___ mg/kg
Specify source


ATGAM (horse) – Go to question 135



ATG – Fresenius (rabbit) – Go to question 135



Thymoglobulin (rabbit) – Go to question 135



Other – Go to question 134
Specify other source: _____________________

CIBMTR Form 2400 R8 (page 22 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

Alemtuzumab (Campath)


Yes – Go to question 136



No – Go to question 137
Total prescribed dose: __ __ __ __ . __  mg/m2
 mg/kg
mg

Defibrotide


Yes



No

KGF


Yes



No

Ursodiol


Yes



No

GVHD Prophylaxis

This section is to be completed for allogeneic HCTs only; autologous HCTs continue with question 143.
Was GVHD prophylaxis planned?


Yes - Go to question 141



No - Go to question 143
Specify drugs / intervention (check all that apply)


Abatacept



Anti CD 25 (Zenapax, Daclizumab, AntiTAC)



Blinded randomized trial



Bortezomib



CD34 enriched (CD34+ selection)



Corticosteroids (systemic)



Cyclophosphamide (Cytoxan)

CIBMTR Form 2400 R8 (page 23 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



Cyclosporine (CSA, Neoral, Sandimmune)



Extra-corporeal photopheresis (ECP)



Ex-vivo T-cell depletion



Filgotinib



Maraviroc



Methotrexate (MTX) (Amethopterin)



Mycophenolate mofetil (MMF) (CellCept)



Ruxolotinib



Sirolimus (Rapamycin, Rapamune)



Tacrolimus (FK 506)



Tocilizumab



Other agent-go to question 142
Specify other agent: ______________ (do not report ATG, campath)

Post-HCT Disease Therapy Planned as of Day 0

Is additional post-HCT therapy planned?

 Yes - Go to question 144
 No - Go to First Name

Questions 144-145 are optional for non-U.S. centers
Specify post-HCT therapy planned (check all that apply)


Azacytidine (Vidaza)



Blinatumomab



Bortezomib (Velcade)



Bosutinib



Brentuximab



Carfilzomib



Cellular therapy (e.g. DCI, DLI)



Crenolanib



Daratumumab



Dasatinib



Decitabine



Elotuzumab



Enasidenib

CIBMTR Form 2400 R8 (page 24 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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



Gilteritinib



Ibrutinib



Imatinib mesylate (Gleevec, Glivec)



Intrathecal therapy (chemotherapy)



Ivosidenib



Ixazomib



Lenalidomide (Revlimid)



Lestaurtinib



Local radiotherapy



Midostaurin



Nilotinib



Obinutuzumab



Pacritinib



Ponatinib



Quizartinib



Rituximab (Rituxan, MabThera)



Sorafenib



Sunitinib



Thalidomide (Thalomid)



Other therapy- Go to question 145



Unknown
Specify other therapy: ____________________________

Prior Exposure: Potential Study Eligibility

Selecting any option(s) below may generate an additional supplemental form.
Specify if the recipient received any of the following (at any time prior to HCT / infusion) (check all that apply)


Blinatumomab (Blincyto)



Gemtuzumab ozogamicin (Mylotarg)



Inotuzumab ozogamicin (Besponsa)



Adienne Tepadina®



Mogamulizumab (Poteligeo)



None of the above

CIBMTR Form 2400 R8 (page 25 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

CIBMTR Center Number: ___ ___ ___ ___ ___

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

First Name: ____________________________________________________________________________

Last Name:

____________________________________________________________________________

E-mail address: _________________________________________________________________________________

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

MM

DD

CIBMTR Form 2400 R8 (page 26 of 26). OMB No: 0915-0310. Expiration Date: 10/31/2022. Form Released 22 January 2021. Last Updated 22 January 2021.
Copyright © 2021 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.