Information Collection Domain Pre-Transplant Information Collection
5e - Information Collection Domain_Pre-Transplant Information Collection _SCTOD.xlsx
Stem Cell Therapeutic Outcomes Database
Information Collection Domain Pre-Transplant Information Collection
OMB: 0915-0310
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Transplant Procedure&Produc
Post-Transplant Periodic Inform
Header Definitions
Change Summary
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Overview
Pre-Transplant Information CollTransplant Procedure&Produc
Post-Transplant Periodic Inform
Header Definitions
Change Summary
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Sheet 1: Pre-Transplant Information Coll
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Information Collection Domain: Pre-Transplant Information Collection | ||||||||
| Information Collection Domain Sub-Type | Information Collection Domain Additional Sub Domain | Response required if Additional Sub Domain applies | Information Collection may be requested multiple times | Current Information Collection Data Element (if applicable) | Current Information Collection Data Element Response Option(s) | Information Collection update: | Proposed Information Collection Data Element (if applicable) | Proposed Information Collection Data Element Response Option(s) | Rationale for Information Collection Update |
| Pre-Transplant Essential Data | no | no | Sequence Number: | Auto Filled Field | Sequence Number: | Auto Filled Field | |||
| Pre-Transplant Essential Data | no | no | Date Received: | Auto Filled Field | Date Received: | Auto Filled Field | |||
| Pre-Transplant Essential Data | no | no | CIBMTR Center Number: | Auto Filled Field | CIBMTR Center Number: | Auto Filled Field | |||
| Pre-Transplant Essential Data | no | no | EBMT Code (CIC): | Auto Filled Field | EBMT Code (CIC): | Auto Filled Field | |||
| Pre-Transplant Essential Data | no | no | CIBMTR Research ID: | Auto Filled Field | CIBMTR Research ID: | Auto Filled Field | |||
| Pre-Transplant Essential Data | no | no | Event date: | Auto Filled Field created with CRID | Event date: | Auto Filled Field created with CRID | |||
| Pre-Transplant Essential Data | no | no | Date of birth: | YYYY/MM/DD | Date of birth: | YYYY/MM/DD | |||
| Pre-Transplant Essential Data | no | no | Sex | female,male | Sex | female,male | |||
| Pre-Transplant Essential Data | no | no | Ethnicity | Hispanic or Latino,Not applicable (not a resident of the USA),Not Hispanic or Latino,Unknown | Ethnicity | Hispanic or Latino,Not applicable (not a resident of the USA),Not Hispanic or Latino,Unknown | |||
| Pre-Transplant Essential Data | no | no | Race (check all that apply) | American Indian or Alaska Native,Asian,Black or African American,Not reported,Native Hawaiian or Other Pacific Islander,Unknown,White | Race (check all that apply) | American Indian or Alaska Native,Asian,Black or African American,Not reported,Native Hawaiian or Other Pacific Islander,Unknown,White | |||
| Pre-Transplant Essential Data | no | no | Race detail (check all that apply) | African American,African (both parents born in Africa),South Asian,American Indian, South or Central America,Alaskan Native or Aleut,North American Indian,Black Caribbean,Caribbean Indian,Other White,Eastern European,Filipino (Pilipino),Guamanian,Hawaiian,Japanese,Korean,Mediterranean,Middle Eastern,North American,North Coast of Africa,Chinese,Northern European,Other Pacific Islander,Other Black,Samoan,Black South or Central American,Other Southeast Asian,Unknown,Vietnamese,White Caribbean,Western European,White South or Central American | Race detail (check all that apply) | African American,African (both parents born in Africa),South Asian,American Indian, South or Central America,Alaskan Native or Aleut,North American Indian,Black Caribbean,Caribbean Indian,Other White,Eastern European,Filipino (Pilipino),Guamanian,Hawaiian,Japanese,Korean,Mediterranean,Middle Eastern,North American,North Coast of Africa,Chinese,Northern European,Other Pacific Islander,Other Black,Samoan,Black South or Central American,Other Southeast Asian,Unknown,Vietnamese,White Caribbean,Western European,White South or Central American | |||
| Pre-Transplant Essential Data | no | no | Country of primary residence | Andorra,United Arab Emirates,Afghanistan,Antigua and Barbuda,Anguilla,Albania,Armenia,Netherlands Antilles,Angola,Antarctica,Argentina,American Samoa,Austria,Australia,Aruba,Aland Islands,Azerbaijan,Bosnia and Herzegovina,Barbados,Bangladesh,Belgium,Burkina Faso,Bulgaria,Bahrain,Burundi,Benin,Saint Barthelemy,Bermuda,Brunei Darussalam,Bolivia,Bonaire, Sint Eustatius and Saba,Brazil,Bahamas,Bhutan,Bouvet Island,Botswana,Belarus,Belize,Canada,Cocos (Keeling) Islands,Congo, Democratic Republic of the,Central African Republic,Congo, Republic of the,Switzerland,Cote d'Ivoire,Cook Islands,Chile,Cameroon,China,Colombia,Costa Rica,Cuba,Cape Verde,Curacao,Christmas Island,Cyprus,Czech Republic,Germany,Djibouti,Denmark,Dominica,Dominican Republic,Algeria,Ecuador,Estonia,Egypt,Western Sahara,Eritrea,Spain,Ethiopia,Finland,Fiji,Falkland Islands,Micronesia,Faroe Islands,France,Gabon,United Kingdom (England, Wales, Scotland, Northern Ireland),Grenada,Georgia,French Guiana,Guernsey,Ghana,Gibraltar,Greenland,Gambia,Guinea,Guadeloupe,Equatorial Guinea,Greece,South Georgia and the South Sandwich Islands,Guatemala,Guam,Guinea-Bissau,Guyana,Hong Kong,Heard Island and McDonald Islands,Honduras,Croatia,Haiti,Hungary,Indonesia,Ireland,Israel,Isle of Man,India,British Indian Ocean Territory,Iraq,Iran,Iceland,Italy,Jersey,Jamaica,Jordan,Japan,Kenya,Kyrgyzstan,Cambodia,Kiribati,Comoros,Saint Kitts and Nevis,North Korea,South Korea,Kuwait,Cayman Islands,Kazakhstan,Laos,Lebanon,Saint Lucia,Liechtenstein,Sri Lanka,Liberia,Lesotho,Lithuania,Luxembourg,Latvia,Libya,Morocco,Monaco,Moldova,Montenegro,Saint Martin, French,Madagascar,Marshall Islands,Macedonia,Mali,Myanmar,Mongolia,Macau,Northern Mariana Islands,Martinique,Mauritania,Montserrat,Malta,Mauritius,Maldives,Malawi,Mexico,Malaysia,Mozambique,Namibia,New Caledonia,Niger,Norfolk Island,Nigeria,Nicaragua,Netherlands,Norway,Nepal,Nauru,Niue,New Zealand,Oman,Panama,Peru,French Polynesia,Papua New Guinea,Philippines,Pakistan,Poland,Saint Pierre and Miquelon,Pitcairn Islands,Puerto Rico,Palestine, State of,Portugal,Palau,Paraguay,Qatar,Reunion,Romania,Serbia,Russia,Rwanda,Saudi Arabia,Solomon Islands,Seychelles,Sudan,Sweden,Singapore,Saint Helena,Slovenia,Svalbard and Jan Mayen,Slovak Republic,Sierra Leone,San Marino,Senegal,Somalia,Suriname,South Sudan,Sao Tome and Principe,El Salvador,Sint Maarten, Dutch,Syria,Swaziland,Turks and Caicos Islands,Chad,French Southern Territories,Togo,Thailand,Tajikistan,Tokelau,Timor-Leste,Turkmenistan,Tunisia,Tonga,Turkey,Trinidad and Tobago,Tuvalu,Taiwan,Tanzania,Ukraine,Uganda,United States Minor Outlying Islands,United States,Uruguay,Uzbekistan,Holy See,Saint Vincent and the Grenadines,Venezuela,British Virgin Islands,United States Virgin Islands,Vietnam,Vanuatu,Wallis and Futuna Islands,Samoa,Yemen,Mayotte,South Africa,Zambia,Zimbabwe | Country of primary residence | Andorra,United Arab Emirates,Afghanistan,Antigua and Barbuda,Anguilla,Albania,Armenia,Netherlands Antilles,Angola,Antarctica,Argentina,American Samoa,Austria,Australia,Aruba,Aland Islands,Azerbaijan,Bosnia and Herzegovina,Barbados,Bangladesh,Belgium,Burkina Faso,Bulgaria,Bahrain,Burundi,Benin,Saint Barthelemy,Bermuda,Brunei Darussalam,Bolivia,Bonaire, Sint Eustatius and Saba,Brazil,Bahamas,Bhutan,Bouvet Island,Botswana,Belarus,Belize,Canada,Cocos (Keeling) Islands,Congo, Democratic Republic of the,Central African Republic,Congo, Republic of the,Switzerland,Cote d'Ivoire,Cook Islands,Chile,Cameroon,China,Colombia,Costa Rica,Cuba,Cape Verde,Curacao,Christmas Island,Cyprus,Czech Republic,Germany,Djibouti,Denmark,Dominica,Dominican Republic,Algeria,Ecuador,Estonia,Egypt,Western Sahara,Eritrea,Spain,Ethiopia,Finland,Fiji,Falkland Islands,Micronesia,Faroe Islands,France,Gabon,United Kingdom (England, Wales, Scotland, Northern Ireland),Grenada,Georgia,French Guiana,Guernsey,Ghana,Gibraltar,Greenland,Gambia,Guinea,Guadeloupe,Equatorial Guinea,Greece,South Georgia and the South Sandwich Islands,Guatemala,Guam,Guinea-Bissau,Guyana,Hong Kong,Heard Island and McDonald Islands,Honduras,Croatia,Haiti,Hungary,Indonesia,Ireland,Israel,Isle of Man,India,British Indian Ocean Territory,Iraq,Iran,Iceland,Italy,Jersey,Jamaica,Jordan,Japan,Kenya,Kyrgyzstan,Cambodia,Kiribati,Comoros,Saint Kitts and Nevis,North Korea,South Korea,Kuwait,Cayman Islands,Kazakhstan,Laos,Lebanon,Saint Lucia,Liechtenstein,Sri Lanka,Liberia,Lesotho,Lithuania,Luxembourg,Latvia,Libya,Morocco,Monaco,Moldova,Montenegro,Saint Martin, French,Madagascar,Marshall Islands,Macedonia,Mali,Myanmar,Mongolia,Macau,Northern Mariana Islands,Martinique,Mauritania,Montserrat,Malta,Mauritius,Maldives,Malawi,Mexico,Malaysia,Mozambique,Namibia,New Caledonia,Niger,Norfolk Island,Nigeria,Nicaragua,Netherlands,Norway,Nepal,Nauru,Niue,New Zealand,Oman,Panama,Peru,French Polynesia,Papua New Guinea,Philippines,Pakistan,Poland,Saint Pierre and Miquelon,Pitcairn Islands,Puerto Rico,Palestine, State of,Portugal,Palau,Paraguay,Qatar,Reunion,Romania,Serbia,Russia,Rwanda,Saudi Arabia,Solomon Islands,Seychelles,Sudan,Sweden,Singapore,Saint Helena,Slovenia,Svalbard and Jan Mayen,Slovak Republic,Sierra Leone,San Marino,Senegal,Somalia,Suriname,South Sudan,Sao Tome and Principe,El Salvador,Sint Maarten, Dutch,Syria,Swaziland,Turks and Caicos Islands,Chad,French Southern Territories,Togo,Thailand,Tajikistan,Tokelau,Timor-Leste,Turkmenistan,Tunisia,Tonga,Turkey,Trinidad and Tobago,Tuvalu,Taiwan,Tanzania,Ukraine,Uganda,United States Minor Outlying Islands,United States,Uruguay,Uzbekistan,Holy See,Saint Vincent and the Grenadines,Venezuela,British Virgin Islands,United States Virgin Islands,Vietnam,Vanuatu,Wallis and Futuna Islands,Samoa,Yemen,Mayotte,South Africa,Zambia,Zimbabwe | |||
| Pre-Transplant Essential Data | no | no | State of residence of recipient | Acre,Alagoas,Amapa,Amazonas,Bahia,Ceara,Distrito Federal,Espirito Santo,Goias,Maranhao,Mato Grosso,Mato Grosso do Sul,Minas Gerais,Para,Paraiba,Parana,Pernambuco,Piaui,Rio Grande do Norte,Rio Grande do Sul,Rio de Janeiro,Rondonia,Roraima,Santa Catarina,Sao Paulo,Sergipe,Tocantins | State of residence of recipient | Acre,Alagoas,Amapa,Amazonas,Bahia,Ceara,Distrito Federal,Espirito Santo,Goias,Maranhao,Mato Grosso,Mato Grosso do Sul,Minas Gerais,Para,Paraiba,Parana,Pernambuco,Piaui,Rio Grande do Norte,Rio Grande do Sul,Rio de Janeiro,Rondonia,Roraima,Santa Catarina,Sao Paulo,Sergipe,Tocantins | |||
| Pre-Transplant Essential Data | no | no | Province or territory of residence of recipient | Alberta,British Columbia,Manitoba,New Brunswick,Newfoundland and Labrador,Nova Scotia,Nunavut,Northwest Territories,Ontario,Prince Edward Island,Quebec,Saskatchewan,Yukon | Province or territory of residence of recipient | Alberta,British Columbia,Manitoba,New Brunswick,Newfoundland and Labrador,Nova Scotia,Nunavut,Northwest Territories,Ontario,Prince Edward Island,Quebec,Saskatchewan,Yukon | |||
| Pre-Transplant Essential Data | no | no | State of residence of recipient | Alaska,Alabama,Arkansas,Arizona,California,Colorado,Connecticut,District of Columbia,Delaware,Florida,Georgia,Hawaii,Iowa,Idaho,Illinois,Indiana,Kansas,Kentucky,Louisiana,Massachusetts,Maryland,Maine,Michigan,Minnesota,Missouri,Mississippi,Montana,North Carolina,North Dakota,Nebraska,New Hampshire,New Jersey,New Mexico,Nevada,New York,Ohio,Oklahoma,Oregon,Pennsylvania,Rhode Island,South Carolina,South Dakota,Tennessee,Texas,Utah,Virginia,Vermont,Washington,Wisconsin,West Virginia,Wyoming | State of residence of recipient | Alaska,Alabama,Arkansas,Arizona,California,Colorado,Connecticut,District of Columbia,Delaware,Florida,Georgia,Hawaii,Iowa,Idaho,Illinois,Indiana,Kansas,Kentucky,Louisiana,Massachusetts,Maryland,Maine,Michigan,Minnesota,Missouri,Mississippi,Montana,North Carolina,North Dakota,Nebraska,New Hampshire,New Jersey,New Mexico,Nevada,New York,Ohio,Oklahoma,Oregon,Pennsylvania,Rhode Island,South Carolina,South Dakota,Tennessee,Texas,Utah,Virginia,Vermont,Washington,Wisconsin,West Virginia,Wyoming | |||
| Pre-Transplant Essential Data | no | no | NMDP Recipient ID (RID): | open text | NMDP Recipient ID (RID): | open text | |||
| Pre-Transplant Essential Data | no | no | Zip or postal code for place of recipient's residence (USA and Canada residents only): | open text | Zip or postal code for place of recipient's residence (USA and Canada residents only): | open text | |||
| Pre-Transplant Essential Data | Allogeneic Recipient | yes | no | 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)? | No (recipient declined),Not applicable (center not participating), Not approached,Yes (recipient consented) | 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)? | No (recipient declined),Not applicable (center not participating), Not approached,Yes (recipient consented) | ||
| Pre-Transplant Essential Data | Allogeneic Recipient | yes | no | Date form was signed: | YYYY/MM/DD | Date form was signed: | YYYY/MM/DD | ||
| Pre-Transplant Essential Data | Related Donors | yes | no | Did the recipient submit a research sample to the NMDP/CIBMTR repository? (Related donors only) | no,yes | Did the recipient submit a research sample to the NMDP/CIBMTR repository? (Related donors only) | no,yes | ||
| Pre-Transplant Essential Data | Related Donors | yes | no | Research sample recipient ID: | open text | Research sample recipient ID: | open text | ||
| Pre-Transplant Essential Data | Is the recipient participating in a clinical trial? (clinical trial sponsors that use CIBMTR forms to capture outcomes data) | no,yes | Is the recipient participating in a clinical trial? (clinical trial sponsors that use CIBMTR forms to capture outcomes data) | no,yes | |||||
| Pre-Transplant Essential Data | Clinical Trial Participants | yes | no | Study Sponsor | BMT CTN,COG,Other,PIDTC,RCI BMT,USIDNET | Change/Clarification of Response Options | Study Sponsor | BMT CTN,COG,Other,PIDTC,RCI BMT,USIDNET, PedAL | Be consistent with current clinical landscape, improve transplant outcome data |
| Pre-Transplant Essential Data | Clinical Trial Participants | yes | no | Specify other sponsor: | open text | Specify other sponsor: | open text | ||
| Pre-Transplant Essential Data | Clinical Trial Participants | yes | no | Study ID Number | A Representative list of current response options is shown here. This list will change on a frequent basis to accommodate updates – changes in the response options do not affect burden of completing this question. BMT CTN 0301 - Aplastic Anemia,BMT CTN 0601 - Sickle Cell Anemia,BMT CTN 0701 - Follicular Lymphoma,BMT CTN 0702 - Myeloma,BMT CTN 0801 - Chronic GVHD Treatment,BMT CTN 0803 - Auto HCT in HIV + Patients,RCI BMT 09 - MRD,RCI BMT 09 - Plex,BMT CTN 0901 - Myeloablative vs. RIC,BMT CTN 0902 - Peri-TX Stress Mgmt,BMT CTN 0903 - Allo HCT in HIV + Patients,RCI BMT 10 - CBA,RCI BMT 10-CMSMDS-1,RCI BMT 11 - Treo,BMT CTN 1101 - Haplo vs. Double UCB with RIC,BMT CTN 1102 - MDS in older patients,RCI BMT 12 - Moxe,BMT CTN 1202 - Biomarker,BMT CTN 1203 - GVHD Prophylaxis,BMT CTN 1204 - HLH,BMT CTN 1205 - Easy-to-read Consent Form (ETRIC),RCI BMT 13 - TLEC,BMT CTN 1301 - CNI-Free,BMT CTN 1302 - Allo MM,BMT CTN 1401 - Myeloma Vaccine,RCI BMT 145-ADS-202,RCI BMT 15 - MMUD,BMT CTN 1501 - Standard Risk GVHD,BMT CTN 1502 - CHAMP Aplastic Anemia,BMT CTN 1503 - STRIDE2,BMT CTN 1506 - AML Maintenance Therapy,BMT CTN 1507 - Haplo Sickle Cell,RCI BMT 16-CMS-MF,RCI BMT 16 - NTCD,RCI BMT 17- CD33,RCI BMT 17-CMS-MM,RCI BMT 17-CMS-SCD,RCI BMT 17 - CSIDE,BMT CTN 1703 - PROGRESS III,BMT CTN 1704 - CHARM,BMT CTN 1803 - Haplo NK Cell,BMT CTN 1903 - HIV T Cell,BMT CTN 1904 - Treo BM Failure Syndromes,BMT CTN 1905 - BEAT-MS (ITN077AI),PIDTC 6901 - Disorders of the immune system (SCID),PIDTC 6903 - Disorders of the immune system (CGD),PIDTC 6904 - Disorders of the immune system (WAS),RCI BMT ACCESS,RCI BMT KIR - DS,RCI BMT SQOL | Study ID Number | A Representative list of current response options is shown here. This list will change on a frequent basis to accommodate updates – changes in the response options do not affect burden of completing this question.BMT CTN 0301 - Aplastic Anemia,BMT CTN 0601 - Sickle Cell Anemia,BMT CTN 0701 - Follicular Lymphoma,BMT CTN 0702 - Myeloma,BMT CTN 0801 - Chronic GVHD Treatment,BMT CTN 0803 - Auto HCT in HIV + Patients,RCI BMT 09 - MRD,RCI BMT 09 - Plex,BMT CTN 0901 - Myeloablative vs. RIC,BMT CTN 0902 - Peri-TX Stress Mgmt,BMT CTN 0903 - Allo HCT in HIV + Patients,RCI BMT 10 - CBA,RCI BMT 10-CMSMDS-1,RCI BMT 11 - Treo,BMT CTN 1101 - Haplo vs. Double UCB with RIC,BMT CTN 1102 - MDS in older patients,RCI BMT 12 - Moxe,BMT CTN 1202 - Biomarker,BMT CTN 1203 - GVHD Prophylaxis,BMT CTN 1204 - HLH,BMT CTN 1205 - Easy-to-read Consent Form (ETRIC),RCI BMT 13 - TLEC,BMT CTN 1301 - CNI-Free,BMT CTN 1302 - Allo MM,BMT CTN 1401 - Myeloma Vaccine,RCI BMT 145-ADS-202,RCI BMT 15 - MMUD,BMT CTN 1501 - Standard Risk GVHD,BMT CTN 1502 - CHAMP Aplastic Anemia,BMT CTN 1503 - STRIDE2,BMT CTN 1506 - AML Maintenance Therapy,BMT CTN 1507 - Haplo Sickle Cell,RCI BMT 16-CMS-MF,RCI BMT 16 - NTCD,RCI BMT 17- CD33,RCI BMT 17-CMS-MM,RCI BMT 17-CMS-SCD,RCI BMT 17 - CSIDE,BMT CTN 1703 - PROGRESS III,BMT CTN 1704 - CHARM,BMT CTN 1803 - Haplo NK Cell,BMT CTN 1903 - HIV T Cell,BMT CTN 1904 - Treo BM Failure Syndromes,BMT CTN 1905 - BEAT-MS (ITN077AI),PIDTC 6901 - Disorders of the immune system (SCID),PIDTC 6903 - Disorders of the immune system (CGD),PIDTC 6904 - Disorders of the immune system (WAS),RCI BMT ACCESS,RCI BMT KIR - DS,RCI BMT SQOL | ||
| Pre-Transplant Essential Data | Clinical Trial Participants | yes | no | Subject ID: | open text | Subject ID: | open text | ||
| Pre-Transplant Essential Data | Clinical Trial Participants | yes | no | Specify the ClinicalTrials.gov identification number: | open text | Specify the ClinicalTrials.gov identification number: | open text | ||
| Pre-Transplant Essential Data | Autologous Transplant | yes | no | 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) | no,yes | 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) | no,yes | ||
| Pre-Transplant Essential Data | Autologous Transplant | yes | no | Specify subsequent HCT planned | Allogeneic,Autologous | Specify subsequent HCT planned | Allogeneic,Autologous | ||
| Pre-Transplant Essential Data | Has the recipient ever had a prior HCT? | No,Yes | Has the recipient ever had a prior HCT? | No,Yes | |||||
| Pre-Transplant Essential Data | Specify the number of prior HCTs: | open text | Specify the number of prior HCTs: | open text | |||||
| Pre-Transplant Essential Data | Were all prior HCTs reported to the CIBMTR? | No,Unknown,Yes | Were all prior HCTs reported to the CIBMTR? | No,Unknown,Yes | |||||
| Pre-Transplant Essential Data | Prior Transplant | yes | yes | Date of the prior HCT: | YYYY/MM/DD | Date of the prior HCT: | YYYY/MM/DD | ||
| Pre-Transplant Essential Data | Prior Transplant | yes | yes | Date estimated | checked | Date estimated | checked | ||
| Pre-Transplant Essential Data | Prior Transplant | yes | yes | Was the prior HCT performed at a different institution? | No,Yes | Was the prior HCT performed at a different institution? | No,Yes | ||
| Pre-Transplant Essential Data | Prior Transplant | yes | yes | Name: | open text | Name: | open text | ||
| Pre-Transplant Essential Data | Prior Transplant | yes | yes | City: | open text | City: | open text | ||
| Pre-Transplant Essential Data | Prior Transplant | yes | yes | State: | open text | State: | open text | ||
| Pre-Transplant Essential Data | Prior Transplant | yes | yes | Country: | open text | Country: | open text | ||
| Pre-Transplant Essential Data | Prior Transplant | yes | yes | What was the HPC source for the prior HCT? (check all that apply) | Allogeneic - related, Allogeneic -unrelated, Autologous | What was the HPC source for the prior HCT? (check all that apply) | Allogeneic - related, Allogeneic -unrelated, Autologous | ||
| Pre-Transplant Essential Data | no | no | Reason for current HCT | Graft failure / insufficient hematopoietic recovery,Insufficient chimerism,New malignancy (including PTLD and EBV lymphoma),Other,Persistent primary disease,Planned subsequent HCT, per protocol,Recurrent primary disease | Reason for current HCT | Graft failure / insufficient hematopoietic recovery,Insufficient chimerism,New malignancy (including PTLD and EBV lymphoma),Other,Persistent primary disease,Planned subsequent HCT, per protocol,Recurrent primary disease | |||
| Pre-Transplant Essential Data | no | no | Date of graft failure / rejection: | YYYY/MM/DD | Date of graft failure / rejection: | YYYY/MM/DD | |||
| Pre-Transplant Essential Data | no | no | Date of relapse: | YYYY/MM/DD | Date of relapse: | YYYY/MM/DD | |||
| Pre-Transplant Essential Data | no | no | Date of secondary malignancy: | YYYY/MM/DD | Date of secondary malignancy: | YYYY/MM/DD | |||
| Pre-Transplant Essential Data | no | no | Specify other reason: | open text | Specify other reason: | open text | |||
| Pre-Transplant Essential Data | no | no | Has the recipient ever had a prior cellular therapy? (do not include DLIs) | No,Unknown,Yes | Has the recipient ever had a prior cellular therapy? (do not include DLIs) | No,Unknown,Yes | |||
| Pre-Transplant Essential Data | Prior Cellular Therapies | yes | no | Were all prior cellular therapies reported to the CIBMTR? | No,Unknown,Yes | Were all prior cellular therapies reported to the CIBMTR? | No,Unknown,Yes | ||
| Pre-Transplant Essential Data | Prior Cellular Therapies | yes | no | Date of the prior cellular therapy: | YYYY/MM/DD | Date of the prior cellular therapy: | YYYY/MM/DD | ||
| Pre-Transplant Essential Data | Prior Cellular Therapies | yes | no | Was the cellular therapy performed at a different institution? | No,Yes | Was the cellular therapy performed at a different institution? | No,Yes | ||
| Pre-Transplant Essential Data | Prior Cellular Therapies | yes | no | Name: | open text | Name: | open text | ||
| Pre-Transplant Essential Data | Prior Cellular Therapies | yes | no | City: | open text | City: | open text | ||
| Pre-Transplant Essential Data | Prior Cellular Therapies | yes | no | State: | open text | State: | open text | ||
| Pre-Transplant Essential Data | Prior Cellular Therapies | yes | no | Country: | open text | Country: | open text | ||
| Pre-Transplant Essential Data | Prior Cellular Therapies | yes | no | Specify the source(s) for the prior cellular therapy (check all that apply) | Allogeneic-related,Allogeneic-unrelated,Autologous | Specify the source(s) for the prior cellular therapy (check all that apply) | Allogeneic-related,Allogeneic-unrelated,Autologous | ||
| Pre-Transplant Essential Data | no | no | Multiple donors? | no,yes | Multiple donors? | no,yes | |||
| Pre-Transplant Essential Data | no | no | Specify number of donors: | open text | Specify number of donors: | open text | |||
| Pre-Transplant Essential Data | no | yes | Specify donor | Allogeneic-related donor,Allogeneic-unrelated donor,Autologous | Specify donor | Allogeneic-related donor,Allogeneic-unrelated donor,Autologous | |||
| Pre-Transplant Essential Data | no | yes | Specify product type (check all that apply) | Bone marrow,Other product,PBSC,Single cord blood unit | Specify product type (check all that apply) | Bone marrow,Other product,PBSC,Single cord blood unit | |||
| Pre-Transplant Essential Data | no | yes | Specify other product: | open text | Specify other product: | open text | |||
| Pre-Transplant Essential Data | yes | yes | Is the product genetically modified? | No,Yes | Is the product genetically modified? | No,Yes | |||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Specify the related donor type | HLA-matched other relative,HLA-mismatched relative,HLA-identical sibling (may include non-monozygotic twin),Syngeneic (monozygotic twin) | Specify the related donor type | HLA-matched other relative,HLA-mismatched relative,HLA-identical sibling (may include non-monozygotic twin),Syngeneic (monozygotic twin) | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Specify the biological relationship of the donor to the recipient | Fraternal twin,Father,Grandchild,Grandparent,Mother,Maternal aunt,Maternal cousin,Maternal uncle,Other biological relative,Paternal aunt,Paternal cousin,Paternal uncle,Recipient's child,Sibling | Specify the biological relationship of the donor to the recipient | Fraternal twin,Father,Grandchild,Grandparent,Mother,Maternal aunt,Maternal cousin,Maternal uncle,Other biological relative,Paternal aunt,Paternal cousin,Paternal uncle,Recipient's child,Sibling | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Specify other biological relative: | open text | Specify other biological relative: | open text | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Degree of mismatch (related donors only) | 1 HLA antigen mismatch, greater than or equal to 2 HLA antigen mismatch (does include haploidentical donor) | Degree of mismatch (related donors only) | 1 HLA antigen mismatch, greater than or equal to 2 HLA antigen mismatch (does include haploidentical donor) | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Specify unrelated donor type | HLA matched unrelated,HLA mismatched unrelated | Specify unrelated donor type | HLA matched unrelated,HLA mismatched unrelated | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Did NMDP / Be the Match facilitate the procurement, collection, or transportation of the product? | No,Yes | Did NMDP / Be the Match facilitate the procurement, collection, or transportation of the product? | No,Yes | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Was this donor used for any prior HCTs? (for this recipient) | no,yes | Was this donor used for any prior HCTs? (for this recipient) | no,yes | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Global Registration Identifier for Donors (GRID) | open text | Global Registration Identifier for Donors (GRID) | open text | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | NMDP cord blood unit ID: | open text | NMDP cord blood unit ID: | open text | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Non-NMDP unrelated donor ID: | open text | Change/Clarification of Information Requested | Non-NMDP unrelated donor ID:Registry donor ID: | open text | Capture data accurately |
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Non-NMDP cord blood unit ID: | open text | Non-NMDP cord blood unit ID: | open text | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Is the CBU ID also the ISBT DIN number? | No,Unknown,Yes | Is the CBU ID also the ISBT DIN number? | No,Unknown,Yes | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Specify the ISBT DIN number: | open text | Specify the ISBT DIN number: | open text | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Registry or UCB Bank ID | (A) Austrian Bone Marrow Donors,(ACB) Austrian Cord Blood Registry,(ACCB) StemCyte, Inc,(AE) Emirates Bone Marrow Donor Registry,(AM) Armenian Bone Marrow Donor Registry Charitable Trust,(AOCB) University of Colorado Cord Blood Bank,(AR) Argentine CPH Donors Registry,(ARCB) BANCEL - Argentina Cord Blood Bank,(AUCB) Australian Cord Blood Registry,(AUS) Australian / New Zealand Bone Marrow Donor Registry,(B) Marrow Donor Program Belgium,(BCB) Belgium Cord Blood Registry,(BG) Bulgarian Bone Marrow Donor Registry,(BR) INCA/REDOMO,(BSCB) British Bone Marrow Registry - Cord Blood,(CB) Cord Blood Registry,(CH) Swiss BloodStem Cells - Adult Donors,(CHCB) Swiss Blood Stem Cells - Cord Blood,(CKCB) Celgene Cord Blood Bank,(CN) China Marrow Donor Program (CMDP),(CNCB) Shan Dong Cord Blood Bank,(CND) Canadian Blood Services Bone Marrow Donor Registry,(CS2) Czech National Marrow Donor Registry,(CSCR) Czech Stem Cells Registry,(CY) Cyprus Paraskevaidio Bone Marrow Donor Registry,(CY2) The Cyprus Bone Marrow Donor Registry,(D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors,(DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood,(DK) The Danish Bone Marrow Donor Registry,(DK2) Bone Marrow Donors Copenhagen (BMDC),(DUCB) German Branch of the European Cord Blood Bank,(E) REDMO,(ECB) Spanish Cord Blood Registry,(F) France Greffe de Moelle - Adult Donors,(FCB) France Greffe de Moelle - Cord Blood,(FI) Finnish Bone Marrow Donor Registry,(FICB) Finnish Cord Blood Registry,(GB) The Anthony Nolan Trust,(GB3) Welsh Bone Marrow Donor Registry,(GB4) British Bone Marrow Registry,(GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece,(GRCB) Michigan Community Blood Centers Cord Blood Bank,(H) Hungarian Bone Marrow Donor Registry,(HEM) Hema-Quebec,(HK) Hong Kong Bone Marrow Donor Registry,(HR) Croatian Bone Marrow Donor Registry,(I) Italian Bone Marrow Donor Registry,(I3CB) Sheba Medical Centre Cord Blood Registry,(ICB) Italian Cord Blood Bank Network,(IL) Hadassah BMDR,(IL2) Ezer Mizion Bone Marrow Donor Registry,(IL3) Sheba Medical Center Donor Registry,(ILCB) Isreal Cord Blood Bank,(IN) Asian Indian Donor Marrow Registry,(IN2) Dept. of Transfusion Medicine,(IRL) The Irish Unrelated Bone Marrow Panel,(JP) Japan Marrow Donor Program,(KR) Korea Marrow Donor Program,(LT) Lithuanian National Bone Marrow Donor Registry,(LVCB) Leuven Cord Blood Bank,(MACB) Victoria Angel Registry of Hope,(MX) Mexican Bone Marrow Donor Registry,(N) The Norwegian Bone Marrow Donor Registry,(NL) Europdonor Foundation- Adult Donors,(NLCB) Europdonor Foundation - Cord Blood,(NYCB) National Cord Blood Program, New York Blood Center,(OTH) Other Registry,(P) Portuguese Bone Marrow Donors Registry,(PL) National Polish Bone Marrow Registry,(PL2) Unrelated Bone Marrow Donor Registry -Adult Donors,(PL3) Against Leukemia Foundation Marrow Donor Registry,(PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry,(PL5) Polish Central Bone Marrow Donor Registry - Adult Donors,(PMCB) Elie Katz Umbilical Cord Blood Program,(R) Russian Bone Marrow Donor Registry,(R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells,(S) Tobias Registry of Swedish Bone Marrow Donors,(SG) Singapore Bone Marrow Donor Programme (BMDP),(SK) Slovak National Bone Marrow Donor Registry,(SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry,(SLCBB) St Louis Cord Blood Bank,(SLO) Slovenia Donor,(SM) San Marino Bone Marrow Donor Registry,(T1CB) TRAN - Cord Blood,(TACB) StemCyte, Inc. Taiwan,(TECB) Healthbanks Biotech, Co., Ltd,(TH) Thai Stem Cell Donor Registry (TSCDR),(TOCB) Tokyo Cord Blood Bank,(TPCB) BIONET / BabyBanks,(TRAN) TRAN - Adult Donors,(TRIS) Bone Marrow Bank of Istanbul Medical Faculty,(TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors,(TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood,(U1CB) National Marrow Donor Program - Cord Blood,(USA1) National Marrow Donor Program - Adult Donors,(USA2) America Bone Marrow Donor Registry,(UY) SINDOME,(VIAC) Viacord,(W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood,(WACB) Unrelated Bone Marrow Donor Registry - Cord Blood,(ZA) South African Bone Marrow Registry | Registry or UCB Bank ID | (A) Austrian Bone Marrow Donors,(ACB) Austrian Cord Blood Registry,(ACCB) StemCyte, Inc,(AE) Emirates Bone Marrow Donor Registry,(AM) Armenian Bone Marrow Donor Registry Charitable Trust,(AOCB) University of Colorado Cord Blood Bank,(AR) Argentine CPH Donors Registry,(ARCB) BANCEL - Argentina Cord Blood Bank,(AUCB) Australian Cord Blood Registry,(AUS) Australian / New Zealand Bone Marrow Donor Registry,(B) Marrow Donor Program Belgium,(BCB) Belgium Cord Blood Registry,(BG) Bulgarian Bone Marrow Donor Registry,(BR) INCA/REDOMO,(BSCB) British Bone Marrow Registry - Cord Blood,(CB) Cord Blood Registry,(CH) Swiss BloodStem Cells - Adult Donors,(CHCB) Swiss Blood Stem Cells - Cord Blood,(CKCB) Celgene Cord Blood Bank,(CN) China Marrow Donor Program (CMDP),(CNCB) Shan Dong Cord Blood Bank,(CND) Canadian Blood Services Bone Marrow Donor Registry,(CS2) Czech National Marrow Donor Registry,(CSCR) Czech Stem Cells Registry,(CY) Cyprus Paraskevaidio Bone Marrow Donor Registry,(CY2) The Cyprus Bone Marrow Donor Registry,(D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors,(DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood,(DK) The Danish Bone Marrow Donor Registry,(DK2) Bone Marrow Donors Copenhagen (BMDC),(DUCB) German Branch of the European Cord Blood Bank,(E) REDMO,(ECB) Spanish Cord Blood Registry,(F) France Greffe de Moelle - Adult Donors,(FCB) France Greffe de Moelle - Cord Blood,(FI) Finnish Bone Marrow Donor Registry,(FICB) Finnish Cord Blood Registry,(GB) The Anthony Nolan Trust,(GB3) Welsh Bone Marrow Donor Registry,(GB4) British Bone Marrow Registry,(GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece,(GRCB) Michigan Community Blood Centers Cord Blood Bank,(H) Hungarian Bone Marrow Donor Registry,(HEM) Hema-Quebec,(HK) Hong Kong Bone Marrow Donor Registry,(HR) Croatian Bone Marrow Donor Registry,(I) Italian Bone Marrow Donor Registry,(I3CB) Sheba Medical Centre Cord Blood Registry,(ICB) Italian Cord Blood Bank Network,(IL) Hadassah BMDR,(IL2) Ezer Mizion Bone Marrow Donor Registry,(IL3) Sheba Medical Center Donor Registry,(ILCB) Isreal Cord Blood Bank,(IN) Asian Indian Donor Marrow Registry,(IN2) Dept. of Transfusion Medicine,(IRL) The Irish Unrelated Bone Marrow Panel,(JP) Japan Marrow Donor Program,(KR) Korea Marrow Donor Program,(LT) Lithuanian National Bone Marrow Donor Registry,(LVCB) Leuven Cord Blood Bank,(MACB) Victoria Angel Registry of Hope,(MX) Mexican Bone Marrow Donor Registry,(N) The Norwegian Bone Marrow Donor Registry,(NL) Europdonor Foundation- Adult Donors,(NLCB) Europdonor Foundation - Cord Blood,(NYCB) National Cord Blood Program, New York Blood Center,(OTH) Other Registry,(P) Portuguese Bone Marrow Donors Registry,(PL) National Polish Bone Marrow Registry,(PL2) Unrelated Bone Marrow Donor Registry -Adult Donors,(PL3) Against Leukemia Foundation Marrow Donor Registry,(PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry,(PL5) Polish Central Bone Marrow Donor Registry - Adult Donors,(PMCB) Elie Katz Umbilical Cord Blood Program,(R) Russian Bone Marrow Donor Registry,(R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells,(S) Tobias Registry of Swedish Bone Marrow Donors,(SG) Singapore Bone Marrow Donor Programme (BMDP),(SK) Slovak National Bone Marrow Donor Registry,(SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry,(SLCBB) St Louis Cord Blood Bank,(SLO) Slovenia Donor,(SM) San Marino Bone Marrow Donor Registry,(T1CB) TRAN - Cord Blood,(TACB) StemCyte, Inc. Taiwan,(TECB) Healthbanks Biotech, Co., Ltd,(TH) Thai Stem Cell Donor Registry (TSCDR),(TOCB) Tokyo Cord Blood Bank,(TPCB) BIONET / BabyBanks,(TRAN) TRAN - Adult Donors,(TRIS) Bone Marrow Bank of Istanbul Medical Faculty,(TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors,(TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood,(U1CB) National Marrow Donor Program - Cord Blood,(USA1) National Marrow Donor Program - Adult Donors,(USA2) America Bone Marrow Donor Registry,(UY) SINDOME,(VIAC) Viacord,(W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood,(WACB) Unrelated Bone Marrow Donor Registry - Cord Blood,(ZA) South African Bone Marrow Registry | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Specify other Registry or UCB Bank: | open text | Specify other Registry or UCB Bank: | open text | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Donor date of birth | Known,Unknown | Donor date of birth | Known,Unknown | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Donor date of birth: | YYYY/MM/DD | Donor date of birth: | YYYY/MM/DD | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Donor age | Known,Unknown | Donor age | Known,Unknown | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Donor age: Months (use only if less than 1 years old), Years | open text | Donor age: Months (use only if less than 1 years old), Years | open text | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Donor sex | female,male | Donor sex | female,male | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Specify blood type (donor) (non-NMDP allogeneic donors only) | A,AB,B,O | Specify blood type (donor) (non-NMDP allogeneic donors only) | A,AB,B,O | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Specify Rh factor (donor) (non-NMDP allogeneic donors only) | Negative,Positive | Specify Rh factor (donor) (non-NMDP allogeneic donors only) | Negative,Positive | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Donor CMV-antibodies (IgG or Total) (Allogeneic HCTs only) | Indeterminate, Not applicable (cord blood unit), Non-reactive, Not done, Reactive | Donor CMV-antibodies (IgG or Total) (Allogeneic HCTs only) | Indeterminate, Not applicable (cord blood unit), Non-reactive, Not done, Reactive | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | 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) | No (donor declined), Not applicable (center not participating), Not approached, Yes (donor consented) | 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) | No (donor declined), Not applicable (center not participating), Not approached, Yes (donor consented) | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Date form was signed: | YYYY/MM/DD | Date form was signed: | YYYY/MM/DD | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Did the donor submit a research sample to the NMDP/CIBMTR repository? (Related donors only) | no,yes | Did the donor submit a research sample to the NMDP/CIBMTR repository? (related donors only) | no,yes | ||
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Research sample donor ID: | open text | Research sample donor ID: | open text | ||
| Pre-Transplant Essential Data | Autologous Transplant | yes | yes | Specify number of products infused from this donor: | open text | Specify number of products infused from this donor: | open text | ||
| Pre-Transplant Essential Data | Autologous Transplant | yes | yes | Specify the number of these products intended to achieve hematopoietic engraftment: | open text | Specify the number of these products intended to achieve hematopoietic engraftment: | open text | ||
| Pre-Transplant Essential Data | Autologous Transplant | yes | yes | 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, Anti-CD20 (rituximab, Rituxan), Other agent | Change/Clarification of Response Options | What agents were used to mobilize the autologous recipient for this HCT? (check all that apply) | G-CSF (TBO-filgrastim, filgrastim, Granix, Neupogen) ,GM-CSF (sargramostim, Leukine), Pegylated G-CSF (pegfilgrastim, Neulasta), Plerixafor (Mozobil), Combined with chemotherapy, Anti-CD20 (rituximab, Rituxan), Other agent | Be consistent with current clinical landscape, improve transplant outcome data |
| Pre-Transplant Essential Data | Autologous Transplant | yes | yes | Specify other agent: | open text | Specify other agent: | open text | ||
| Pre-Transplant Essential Data | Autologous Transplant | yes | yes | Name of product (gene therapy recipients) | Other name | Name of product (gene therapy recipients) | Other name | ||
| Pre-Transplant Essential Data | Autologous Transplant | yes | yes | Specify other name: | open text | Specify other name: | open text | ||
| Pre-Transplant Essential Data | no | no | What scale was used to determine the recipient’s functional status? | Karnofsky,Lansky | What scale was used to determine the recipient’s functional status? | Karnofsky,Lansky | |||
| Pre-Transplant Essential Data | no | no | Karnofsky Scale (recipient age ≥ 16 years) | 100 Normal; no complaints; no evidence of disease,10 Moribund; fatal process progressing rapidly,20 Very sick; hospitalization necessary,30 Severely disabled; hospitalization indicated, although death not imminent,40 Disabled; requires special care and assistance,50 Requires considerable assistance and frequent medical care,60 Requires occasional assistance but is able to care for most needs,70 Cares for self; unable to carry on normal activity or to do active work,80 Normal activity with effort,90 Able to carry on normal activity | Karnofsky Scale (recipient age ≥ 16 years) | 100 Normal; no complaints; no evidence of disease,10 Moribund; fatal process progressing rapidly,20 Very sick; hospitalization necessary,30 Severely disabled; hospitalization indicated, although death not imminent,40 Disabled; requires special care and assistance,50 Requires considerable assistance and frequent medical care,60 Requires occasional assistance but is able to care for most needs,70 Cares for self; unable to carry on normal activity or to do active work,80 Normal activity with effort,90 Able to carry on normal activity | |||
| Pre-Transplant Essential Data | no | no | Lansky Scale (recipient age ≥ 1 year and < 16 years) | 100 Fully active,10 Completely disabled, not even passive play,20 Limited to very passive activity initiated by others (e.g., TV),30 Needs considerable assistance for quiet activity,40 Able to initiate quiet activities,50 Considerable assistance required for any active play; fully able to engage in quiet play,60 Ambulatory up to 50% of time, limited active play with assistance / supervision,70 Both greater restrictions of, and less time spent in, active play,80 Restricted in strenuous play, tires more easily, otherwise active,90 Minor restriction in physically strenuous play | Lansky Scale (recipient age ≥ 1 year and < 16 years) | 100 Fully active,10 Completely disabled, not even passive play,20 Limited to very passive activity initiated by others (e.g., TV),30 Needs considerable assistance for quiet activity,40 Able to initiate quiet activities,50 Considerable assistance required for any active play; fully able to engage in quiet play,60 Ambulatory up to 50% of time, limited active play with assistance / supervision,70 Both greater restrictions of, and less time spent in, active play,80 Restricted in strenuous play, tires more easily, otherwise active,90 Minor restriction in physically strenuous play | |||
| Pre-Transplant Essential Data | Allogeneic Recipient | yes | no | Specify blood type (of recipient) (For allogeneic HCTs only) | A,AB,B,O | Specify blood type (of recipient) (For allogeneic HCTs only) | A,AB,B,O | ||
| Pre-Transplant Essential Data | Allogeneic Recipient | yes | no | Specify Rh factor (of recipient) (For allogeneic HCTs only) | Negative,Positive | Specify Rh factor (of recipient) (For allogeneic HCTs only) | Negative,Positive | ||
| Pre-Transplant Essential Data | no | no | Recipient CMV-antibodies (IgG or Total) | Indeterminate,Non-reactive,Not done,Reactive | Recipient CMV-antibodies (IgG or Total) | Indeterminate,Non-reactive,Not done,Reactive | |||
| Pre-Transplant Essential Data | 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? | No,Yes | 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? | No,Yes | |||||
| Pre-Transplant Essential Data | Did the patient require hospitalization for management of COVID-19 (SARS-CoV-2) infection? | No,Yes | Did the patient require hospitalization for management of COVID-19 (SARS-CoV-2) infection? | No,Yes | |||||
| Pre-Transplant Essential Data | Was mechanical ventilation used for COVID-19 (SARS-CoV-2) infection? | No,Yes | Change/Clarification of Information Requested | Was mechanical ventilation used given for COVID-19 (SARS-CoV-2) infection? | No,Yes | Examples added or typographical errors corrected for clarification | |||
| Pre-Transplant Essential Data | no | yes | Was a vaccine for COVID-19 (SARS-CoV-2) received? | No,Unknown,Yes | Was a vaccine for COVID-19 (SARS-CoV-2) received? | No,Unknown,Yes | |||
| Pre-Transplant Essential Data | COVID-19 Vaccine | yes | yes | Specify vaccine brand | AstraZeneca,Johnson & Johnson/Janssen,Moderna,Novavax,Other (specify),Pfizer-BioNTech | Specify vaccine brand | AstraZeneca,Johnson & Johnson/Janssen,Moderna,Novavax,Other (specify),Pfizer-BioNTech | ||
| Pre-Transplant Essential Data | COVID-19 Vaccine | yes | yes | Specify other type: | open text | Specify other type: | open text | ||
| Pre-Transplant Essential Data | COVID-19 Vaccine | yes | yes | Select dose(s) received | Booster dose,First dose (with planned second dose) ,One dose (without planned second dose) ,Second dose,Third dose | Select dose(s) received | Booster dose,First dose (with planned second dose) ,One dose (without planned second dose) ,Second dose,Third dose | ||
| Pre-Transplant Essential Data | COVID-19 Vaccine | yes | yes | Date received: | YYYY/MM/DD | Date received: | YYYY/MM/DD | ||
| Pre-Transplant Essential Data | COVID-19 Vaccine | yes | yes | Date estimated | checked | Date estimated | checked | ||
| Pre-Transplant Essential Data | no | no | Is there a history of mechanical ventilation? (excluding COVID-19 (SARS-CoV-2))? | no,yes | Is there a history of mechanical ventilation? (excluding COVID-19 (SARS-CoV-2))? | no,yes | |||
| Pre-Transplant Essential Data | no | no | Is there a history of invasive fungal infection? | No,Yes | Is there a history of invasive fungal infection? | No,Yes | |||
| Pre-Transplant Essential Data | no | no | Glomerular filtration rate (GFR) before start of preparative regimen (pediatric only) | Known,Unknown | Glomerular filtration rate (GFR) before start of preparative regimen (pediatric only) | Known,Unknown | |||
| Pre-Transplant Essential Data | no | no | Glomerular filtration rate (GFR): | __ __ __ mL/min/1.732 | Glomerular filtration rate (GFR): | __ __ __ mL/min/1.732 | |||
| Pre-Transplant Essential Data | no | no | Does the recipient have known complex congenital heart disease? (corrected or uncorrected) (excluding simple ASD, VSD, or PDA repair) (pediatric only) | No,Yes | Does the recipient have known complex congenital heart disease? (corrected or uncorrected) (excluding simple ASD, VSD, or PDA repair) (pediatric only) | No,Yes | |||
| Pre-Transplant Essential Data | no | no | Were there any co-existing diseases or organ impairment present according to the HCT comorbidity index (HCT-CI)? (Source: Sorror, M. L. (2013). How I assess comorbidities before hematopoietic cell transplantation. Blood, 121(15), 2854-2863.) | No,Yes | Were there any co-existing diseases or organ impairment present according to the HCT comorbidity index (HCT-CI)? (Source: Sorror, M. L. (2013). How I assess comorbidities before hematopoietic cell transplantation. Blood, 121(15), 2854-2863.) | No,Yes | |||
| Pre-Transplant Essential Data | Comorbid Conditions | Yes | no | 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 Pulmonary, moderate -Corrected diffusion capacity of carbon monoxide and/or FEV1 of 66-80% 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 102 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 103 |
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 Pulmonary, moderate -Corrected diffusion capacity of carbon monoxide and/or FEV1 of 66-80% 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 102 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 103 |
||
| Pre-Transplant Essential Data | Comorbid Conditions | Yes | no | Was the recipient on dialysis immediately prior to start of preparative regimen? | No,Unknown,Yes | Was the recipient on dialysis immediately prior to start of preparative regimen? | No,Unknown,Yes | ||
| Pre-Transplant Essential Data | Comorbid Conditions | Yes | no | 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 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 cell) Other hematologic malignancy Other solid tumor |
Change/Clarification of Response Options | 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 Acute myeloid leukemia Chronic myeloid leukemia Acute lymphoblastic leukemia Chronic lymphoblastic 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 cell) Other hematologic malignancy Other solid tumor |
Be consistent with current clinical landscape, improve transplant outcome data |
| Pre-Transplant Essential Data | Comorbid Conditions | Yes | no | Specify other skin malignancy: (prior) | open text | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Pre-Transplant Essential Data | Comorbid Conditions | Yes | no | Specify other hematologic malignancy: (prior) | open text | Specify other hematologic malignancy: (prior) | open text | ||
| Pre-Transplant Essential Data | no | no | Specify other solid tumor: (prior) | open text | Specify other solid tumor: (prior) | open text | |||
| Pre-Transplant Essential Data | no | no | Serum ferritin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | Known,Unknown | Serum ferritin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | Known,Unknown | |||
| Pre-Transplant Essential Data | no | no | Serum ferritin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | ___ ___ ___ ___ ___ ng/mL (μg/L) | Serum ferritin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | ___ ___ ___ ___ ___ ng/mL (μg/L) | |||
| Pre-Transplant Essential Data | no | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | |||
| Pre-Transplant Essential Data | no | no | Upper limit of normal for your institution: | open text | Upper limit of normal for your institution: | open text | |||
| Pre-Transplant Essential Data | no | no | Serum albumin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | Known,Unknown | Serum albumin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | Known,Unknown | |||
| Pre-Transplant Essential Data | no | no | Serum albumin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | ___ ___ ● __g/dL ___ ___ ● __ g/L |
Serum albumin (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | ___ ___ ● __g/dL ___ ___ ● __ g/L |
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| Pre-Transplant Essential Data | no | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | |||
| Pre-Transplant Essential Data | no | no | Platelets (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | Known,Unknown | Platelets (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | Known,Unknown | |||
| Pre-Transplant Essential Data | no | no | Platelets (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ x 106/L |
Platelets (within 4 weeks prior to the start of the preparative regimen, use result closest to the start date) | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ x 106/L |
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| Pre-Transplant Essential Data | no | no | Were platelets transfused < 7 days before date of test? | No,Unknown,Yes | Were platelets transfused < 7 days before date of test? | No,Unknown,Yes | |||
| Pre-Transplant Essential Data | no | no | Did the recipient have a prior solid organ transplant? | No,Yes | Did the recipient have a prior solid organ transplant? | No,Yes | |||
| Pre-Transplant Essential Data | Prior Solid Organ Transplant | yes | yes | Specify organ | Bowel,Heart,Kidney(s),Liver,Lung,Other organ,Pancreas | Specify organ | Bowel,Heart,Kidney(s),Liver,Lung,Other organ,Pancreas | ||
| Pre-Transplant Essential Data | Prior Solid Organ Transplant | yes | yes | Specify other organ: | open text | Specify other organ: | open text | ||
| Pre-Transplant Essential Data | Prior Solid Organ Transplant | yes | yes | Year of prior solid organ transplant: | YYYY | Year of prior solid organ transplant: | YYYY | ||
| Pre-Transplant Essential Data | no | no | Height at initiation of pre-HCT preparative regimen: | ___ ___ ___ inches ___ ___ ___ cms |
Change/Clarification of Response Options | Height at initiation of pre-HCT preparative regimen: | ___ ___ ___ inches ___ ___ ___ cms |
Capture data accurately | |
| Pre-HCT Preparative Regimen | no | no | Actual weight at initiation of pre-HCT preparative regimen: | ___ ___ ___ . ___pounds ___ ___ ___ . ___kilograms |
Actual weight at initiation of pre-HCT preparative regimen: | ___ ___ ___ . ___pounds ___ ___ ___ . ___kilograms |
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| Pre-HCT Preparative Regimen | no | no | Was a pre-HCT preparative regimen prescribed? | no,yes | Was a pre-HCT preparative regimen prescribed? | no,yes | |||
| Pre-HCT Preparative Regimen | Allogeneic Recipient | yes | no | Classify the recipient’s prescribed preparative regimen (Allogeneic HCTs only) | Myeloablative,Non-myeloablative (NST),Reduced intensity (RIC) | Classify the recipient’s prescribed preparative regimen (Allogeneic HCTs only) | Myeloablative,Non-myeloablative (NST),Reduced intensity (RIC) | ||
| Pre-HCT Preparative Regimen | no | no | Was irradiation planned as part of the pre-HCT preparative regimen? | no,yes | Was irradiation planned as part of the pre-HCT preparative regimen? | no,yes | |||
| Pre-HCT Preparative Regimen | no | no | What was the prescribed radiation field? | Total body by intensity-modulated radiation therapy (IMRT),Thoracoabdominal region,Total body,Total lymphoid or nodal regions | What was the prescribed radiation field? | Total body by intensity-modulated radiation therapy (IMRT),Thoracoabdominal region,Total body,Total lymphoid or nodal regions | |||
| Pre-HCT Preparative Regimen | no | no | Total prescribed dose: (dose per fraction x total number of fractions) | ___ ___ ___ ___ . ___ Gy ___ ___ ___ ___ . ___ cGy |
Total prescribed dose: (dose per fraction x total number of fractions) | ___ ___ ___ ___ . ___ Gy ___ ___ ___ ___ . ___ cGy |
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| Pre-HCT Preparative Regimen | no | no | Date started: | YYYY/MM/DD | Date started: | YYYY/MM/DD | |||
| Pre-HCT Preparative Regimen | no | no | Was the radiation fractionated? | no,yes | Was the radiation fractionated? | no,yes | |||
| Pre-HCT Preparative Regimen | no | no | Total number of fractions: | open text | Total number of fractions: | open text | |||
| Pre-HCT Preparative Regimen | no | no | Drug (drop down list) | Bendamustine,Busulfan,Carboplatin,Carmustine,Clofarabine,Cyclophosphamide,Cytarabine,Etoposide,Fludarabine,Gemcitabine,Ibritumomab tiuxetan,Ifosfamide,Lomustine,Melphalan,Methylprednisolone,Other,Pentostatin,Propylene glycol-free melphalan,Rituximab,Thiotepa,Tositumomab,Treosulfan | Change/Clarification of Response Options | Drug (drop down list) | Bendamustine,Busulfan,Carboplatin,Carmustine,Clofarabine,Cyclophosphamide,Cytarabine,Etoposide,Fludarabine,Gemcitabine,Ibritumomab tiuxetan,Ifosfamide,Lomustine,Melphalan,Methylprednisolone,Other,Pentostatin,Propylene glycol-free melphalan,Rituximab,Thiotepa,Tositumomab,Treosulfan, Azathioprine, Bortezomib, Cisplatin, Hydroxyurea, and Vincristine. | Be consistent with current clinical landscape, improve transplant outcome data | |
| Pre-HCT Preparative Regimen | no | yes | Specify other drug: | open text | Specify other drug: | open text | |||
| Pre-HCT Preparative Regimen | no | yes | Total prescribed dose: | __ __ __ __ __. __ mg/m2 __ __ __ __ __. __mg/kg __ __ __ __ __. __AUC (mg x h/L) __ __ __ __ __. __AUC (µmol x min/L) __ __ __ __ __. __CSS (ng/mL) |
Total prescribed dose: | __ __ __ __ __. __ mg/m2 __ __ __ __ __. __mg/kg __ __ __ __ __. __AUC (mg x h/L) __ __ __ __ __. __AUC (µmol x min/L) __ __ __ __ __. __CSS (ng/mL) |
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| Pre-HCT Preparative Regimen | no | yes | Date started: | YYYY/MM/DD | Date started: | YYYY/MM/DD | |||
| Pre-HCT Preparative Regimen | no | yes | Specify administration (busulfan only) | Both,IV,Oral | Specify administration (busulfan only) | Both,IV,Oral | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | ALG, ALS, ATG, ATS | no,yes | Change/Clarification of Information Requested and Response Option | ALG, ALS, ATG, ATS, Alemtuzumab, Defibrotide, KGF, Ursodiol | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | ||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Total prescribed dose: | __ __ __ __ __ mg/kg | Total prescribed dose: | __ __ __ __ __ mg/kg | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Specify source | ATGAM (horse),ATG - Fresenius (rabbit),Other,Thymoglobulin (rabbit) | Specify source | ATGAM (horse),ATG - Fresenius (rabbit),Other,Thymoglobulin (rabbit) | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Specify other source: | open text | Specify other source: | open text | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Alemtuzumab (Campath) | no,yes | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Total prescribed dose: | __ __ __ __ . _ mg/m2 __ __ __ __ __ . __mg/kg __ __ __ __ __ . __mg/kg |
Total prescribed dose: | __ __ __ __ . _ mg/m2 __ __ __ __ __ . __mg/kg __ __ __ __ __ . __mg/kg |
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| Additional Drugs Given In the Peri-Transplant Period | no | no | Defibrotide | No,Yes | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | KGF | No,Yes | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Ursodiol | No,Yes | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |||
| GVHD Prophylaxis | Allogeneic Recipient | yes | no | Was GVHD prophylaxis planned? | No,Yes | Was GVHD prophylaxis planned? | No,Yes | ||
| GVHD Prophylaxis | Allogeneic Recipient | yes | no | Specify drugs / intervention (check all that apply) | Abatacept,Anti CD 25(Zenapax, Daclizumab, AntiTAC),Blinded randomized trial,Bortezomib,CD34 enriched(CD34+ selection),Corticosteriods (systemic),Cyclophosphamide (Cytoxan),Cyclosporine (CSA, Neoral, Sandimmune),Extra-corporeal photopheresis (ECP),Ex-vivo T-cell depletion,Filgotinib,Maraviroc,Mycophenolate mofetil (MMF) (Cellcept),Methotrexate (MTX) (Amethopterin),Other agent,Ruxolitinib,Sirolimus (Rapamycin, Rapamune),Tacrolimus(FK 506),Tocilizumab | Specify drugs / intervention (check all that apply) | Abatacept,Anti CD 25(Zenapax, Daclizumab, AntiTAC),Blinded randomized trial,Bortezomib,CD34 enriched(CD34+ selection),Corticosteriods (systemic),Cyclophosphamide (Cytoxan),Cyclosporine (CSA, Neoral, Sandimmune),Extra-corporeal photopheresis (ECP),Ex-vivo T-cell depletion,Filgotinib,Maraviroc,Mycophenolate mofetil (MMF) (Cellcept),Methotrexate (MTX) (Amethopterin),Other agent,Ruxolitinib,Sirolimus (Rapamycin, Rapamune),Tacrolimus(FK 506),Tocilizumab | ||
| GVHD Prophylaxis | Allogeneic Recipient | yes | no | Specify other agent: | open text (do not report ATG, campath) | Specify other agent: | open text (do not report ATG, campath) | ||
| Post-HCT Disease Therapy Planned as of Day 0 | no | no | Is additional post-HCT therapy planned? | no,yes | Is additional post-HCT therapy planned? | no,yes | |||
| Post-HCT Disease Therapy Planned as of Day 0 | no | no | Specify post-HCT therapy planned | Azacitidine(Vidaza),Blinatumomab,Bortezomib (Velcade),Bosutinib,Brentuximab,Carfilzomib,Cellular therapy (e.g. DCI, DLI),Crenolanib,Daratumumab,Dasatinib,Decitabine,Elotuzumab,Enasidenib,Gilteritinib,Ibrutinib,Imanitib mesylate (Gleevec, Glivec),Intrathecal chemotherapy,Ivosidenib,Ixazomib,Lenalidomide (Revlimid),Lestaurtinib,Local radiotherapy,Midostaurin,Nilotinib,Obinutuzumab,Other,Pacritinib,Ponatinib,Quizartinib,Rituximab (Rituxan, Mabthera),Sorafenib,Sunitinib,Thalidomide (Thalomid),Unknown | Specify post-HCT therapy planned | Azacitidine(Vidaza),Blinatumomab,Bortezomib (Velcade),Bosutinib,Brentuximab,Carfilzomib,Cellular therapy (e.g. DCI, DLI),Crenolanib,Daratumumab,Dasatinib,Decitabine,Elotuzumab,Enasidenib,Gilteritinib,Ibrutinib,Imanitib mesylate (Gleevec, Glivec),Intrathecal chemotherapy,Ivosidenib,Ixazomib,Lenalidomide (Revlimid),Lestaurtinib,Local radiotherapy,Midostaurin,Nilotinib,Obinutuzumab,Other,Pacritinib,Ponatinib,Quizartinib,Rituximab (Rituxan, Mabthera),Sorafenib,Sunitinib,Thalidomide (Thalomid),Unknown | |||
| Post-HCT Disease Therapy Planned as of Day 0 | no | no | Specify other therapy: | open text | Specify other therapy: | open text | |||
| Prior Exposure: Potential Study Eligibility | no | no | 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) ,Mogamulizumab (Poteligeo) ,None,Thiotepa | 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) ,Mogamulizumab (Poteligeo) ,None,Thiotepa | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Was the HCT impacted for a reason related to the COVID-19 (SARS-CoV-2) pandemic? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Is the HCT date different than the originally intended HCT date? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Original Date of HCT | YYYY/MM/DD | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Date estimated | checked | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Is the donor different than the originally intended donor? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Specify the originally intended donor | unrelated donor, syngeneic (monozygotic twin) , HLA-idential sibling (may include non-monozygotic twin) , HLA-matched other relative (does NOT include a haplo-identical donor), HLA-mismatched relative | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Is the product type (bone marrow, PBSC, cord blood unit) different than the originally intended product type? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Specify the originally intended product type | bone marrow,Other product,PBSC, cord blood unit | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Specify other product type | open text | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Was the current product thawed from a cryopreserved state prior to infusion? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Did the preparative regimen change from the original plan? | no, yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Did the GVHD prophylaxis change from the original plan? | no,yes | Covid-19 Impact | |||
| Disease Classification | no | yes | Date of diagnosis of primary disease for HCT / cellular therapy: | YYYY/MM/DD | Date of diagnosis of primary disease for HCT / cellular therapy: | YYYY/MM/DD | |||
| Disease Classification | no | no | What was the primary disease for which the HCT / cellular therapy was performed? | Autoimmune diseases,Acute lymphoblastic leukemia (ALL),Acute myelogenous leukemia (AML or ANLL),Chronic myelogenous leukemia (CML),Hemoglobinopathies,Histiocytic disorders,Hodgkin lymphoma,Inherited Bone Marrow Failure Syndromes(If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.)– ,Disorders of the immune system,Inherited disorders of metabolism,Inherited abnormalities of platelets,Myelodysplastic syndrome (MDS) (If recipient has transformed to AML, indicate AML as the primary disease.),Myeloproliferative neoplasms (MPN)(If recipient has transformed to AML, indicate AML as the primary disease.),Non-Hodgkin lymphoma,Acute leukemia of ambiguous lineage and other myeloid neoplasms,Other disease,Other leukemia (includes CLL),Multiple myeloma / plasma cell disorder (PCD),Paroxysmal nocturnal hemoglobinuria (PNH),Recessive dystrophic epidermolysis bullosa,Aplastic Anemia(If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.) ,Solid tumors,Tolerance induction associated with solid organ transplant | Change/Clarification of Response Options | What was the primary disease for which the HCT / cellular therapy was performed? | Autoimmune diseases,Acute lymphoblastic leukemia (ALL),Acute myelogenous myeloid leukemia (AML or ANLL),Chronic myelogenous leukemia (CML),Hemoglobinopathies,Histiocytic disorders,Hodgkin lymphoma,Inherited Bone Marrow Failure Syndromes(If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.)– ,Disorders of the immune system,Inherited disorders of metabolism,Inherited abnormalities of platelets,Myelodysplastic syndrome (MDS) (If recipient has transformed to AML, indicate AML as the primary disease.),Myeloproliferative neoplasms (MPN)(If recipient has transformed to AML, indicate AML as the primary disease.),Non-Hodgkin lymphoma,Acute leukemia of ambiguous lineage and other myeloid neoplasms,Other disease,Other leukemia (includes CLL),Multiple myeloma / plasma cell disorder (PCD),Paroxysmal nocturnal hemoglobinuria (PNH),Recessive dystrophic epidermolysis bullosa,Aplastic Anemia(If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.) ,Solid tumors,Tolerance induction associated with solid organ transplant | Capture data accurately | |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | 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), |
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), |
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| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Did AML transform from MDS or MPN? | no,yes-Also complete MDS or MPN Disease Classification questions | Did AML transform from MDS or MPN? | no,yes-Also complete MDS or MPN Disease Classification questions | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Is the disease (AML) therapy related? | no,Unknown,yes | Is the disease (AML) therapy related? | no,Unknown,yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Did the recipient have a predisposing condition? | no,Unknown,yes | Did the recipient have a predisposing condition? | no,Unknown,yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Specify condition | Bloom syndrome,Dyskeratosis congenita,Down Syndrome,Fanconi anemia,Other condition | Specify condition | Bloom syndrome,Dyskeratosis congenita,Down Syndrome,Fanconi anemia,Other condition | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Specify other condition: | open text | Specify other condition: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis) | no,Unknown,yes | Change/Clarification of Information Requested | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis or relapse) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were tests for molecular markers performed? (at diagnosis) | no,Unknown,yes | Change/Clarification of Information Requested | Were tests for molecular markers performed? (at diagnosis or relapse) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | CEBPA | Negative,Not Done,Positive | CEBPA | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify CEBPA mutation | Biallelic (homozygous),Monoallelic (heterozygous),Unknown | Change/Clarification of Response Options | Specify CEBPA mutation | Biallelic (double mutant),Monoallelic (single mutant),Unknown | Capture data accurately |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 - TKD (point mutations in D835 or deletions of codon I836) | Negative,Not done,Positive | FLT3 - TKD (point mutations in D835 or deletions of codon I836) | Negative,Not done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 – ITD mutation | Negative,Not Done,Positive | FLT3 – ITD mutation | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 - ITD allelic ratio | Known,Unknown | FLT3 - ITD allelic ratio | Known,Unknown | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify FLT3 - ITD allelic ratio: | __ __ . __ __ | Specify FLT3 - ITD allelic ratio: | __ __ . __ __ | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | IDH1 | Negative,Not Done,Positive | IDH1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | IDH2 | Negative,Not Done,Positive | IDH2 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | KIT | Negative,Not Done,Positive | KIT | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | NPM1 | Negative,Not Done,Positive | NPM1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Other molecular marker | Negative,Not Done,Positive | Other molecular marker | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other molecular marker: | open text | Specify other molecular marker: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation) | no,Unknown,yes | Change/Clarification of Information Requested | Were cytogenetics tested (karyotyping or FISH)? (between diagnosis or relapse and last evaluation) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis and last evaluation) | no,Unknown,yes | Change/Clarification of Information Requested | Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis or relapse and last evaluation) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | CEBPA | Negative,Not Done,Positive | CEBPA | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify CEBPA mutation | Biallelic (homozygous),Monoallelic (heterozygous),Unknown | Change/Clarification of Response Options | Specify CEBPA mutation | Biallelic (double mutant),Monoallelic (single mutant),Unknown | Capture data accurately |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 - TKD (point mutations in D835 or deletions of codon I836) | Negative,Not done,Positive | FLT3 - TKD (point mutations in D835 or deletions of codon I836) | Negative,Not done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 – ITD mutation | Negative,Not Done,Positive | FLT3 – ITD mutation | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 - ITD allelic ratio | Known,Unknown | FLT3 - ITD allelic ratio | Known,Unknown | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify FLT3 - ITD allelic ratio: | __ __ . __ __ | Specify FLT3 - ITD allelic ratio: | __ __ . __ __ | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | IDH1 | Negative,Not Done,Positive | IDH1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | IDH2 | Negative,Not Done,Positive | IDH2 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | KIT | Negative,Not Done,Positive | KIT | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | NPM1 | Negative,Not Done,Positive | NPM1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Other molecular marker | Negative,Not Done,Positive | Other molecular marker | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other molecular marker: | open text | Specify other molecular marker: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (at last evaluation) | no,Unknown,yes | Were cytogenetics tested (karyotyping or FISH)? (at last evaluation) | no,Unknown,yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,del(11q) / 11q-,del(16q) / 16q-,del(17q) / 17q-,del(20q) / 20q-,del(21q) / 21q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,inv(16),inv(3),-17,-18,-5,-7,-X,-Y,Other abnormality,t(15;17) and variants,t(16;16),t(3;3),t(6;9),t(8;21),t(9;11),t(9;22),+11,+13,+14,+21,+22,+4,+8 | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were tests for molecular markers performed?(e.g. PCR, NGS) (at last evaluation) | no,Unknown,yes | Were tests for molecular markers performed?(e.g. PCR, NGS) (at last evaluation) | no,Unknown,yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | CEBPA | Negative,Not Done,Positive | CEBPA | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify CEBPA mutation | Biallelic (homozygous),Monoallelic (heterozygous),Unknown | Change/Clarification of Response Options | Specify CEBPA mutation | Biallelic (double mutant),Monoallelic (single mutant),Unknown | Capture data accurately |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 - TKD (point mutations in D835 or deletions of codon I836) | Negative,Not done,Positive | FLT3 - TKD (point mutations in D835 or deletions of codon I836) | Negative,Not done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 – ITD mutation | Negative,Not Done,Positive | FLT3 – ITD mutation | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | FLT3 - ITD allelic ratio | Known,Unknown | FLT3 - ITD allelic ratio | Known,Unknown | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify FLT3 - ITD allelic ratio: | __ __ . __ __ | Specify FLT3 - ITD allelic ratio: | __ __ . __ __ | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | IDH1 | Negative,Not Done,Positive | IDH1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | IDH2 | Negative,Not Done,Positive | IDH2 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | KIT | Negative,Not Done,Positive | KIT | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | NPM1 | Negative,Not Done,Positive | NPM1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Other molecular marker | Negative,Not Done,Positive | Other molecular marker | Negative,Not Done,Positive | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify other molecular marker: | open text | Specify other molecular marker: | open text | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion? | no,Unknown,yes | Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion? | no,Unknown,yes | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | What was the disease status? | 1st complete remission,1st relapse,2nd complete remission,2nd relapse,≥ 3rd complete remission, ≥3rd relapse,No treatment,Primary induction failure | What was the disease status? | 1st complete remission,1st relapse,2nd complete remission,2nd relapse,≥ 3rd complete remission, ≥3rd relapse,No treatment,Primary induction failure | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | How many cycles of induction therapy were required to achieve 1st complete remission? (includes CRi) | 1,2, ≥ 3 | How many cycles of induction therapy were required to achieve 1st complete remission? (includes CRi) | 1,2, ≥ 3 | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Was the recipient in remission by flow cytometry? | Not applicable,No,Unknown,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Specify method(s) that was used to assess measurable residual disease status (check all that apply) | FISH, Karyotyping, Flow Cytometry, PCR, NGS, Not assessed | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by FISH? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by karyotyping assay? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Which leukemia phenotype was used for detection (check all the apply) | original leukemia immunophenotype, aberrant phenotype | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
What is the lower limit of detection (for the original leukemia immunophenotype) | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
What is the lower limit of detection (for the aberrant phenotype) | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by flow cytometry? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by PCR? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by NGS? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Date of most recent relapse: | YYYY/MM/DD | Date of most recent relapse: | YYYY/MM/DD | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | 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 (<46 chromosomes) (83), B-lymphoblastic leukemia / lymphoma, BCR-ABL1-like (provisional entity) (94), B-lymphoblastic leukemia / lymphoma, with iAMP21 (95), T-cell lymphoblastic leukemia / lymphoma: T-cell lymphoblastic leukemia / lymphoma (Precursor T-cell ALL) (196), Early T-cell precursor lymphoblastic leukemia (96),NK cell lymphoblastic leukemia / lymphoma: Natural killer (NK)- cell lymphoblastic leukemia / lymphoma (97) |
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 (<46 chromosomes) (83), B-lymphoblastic leukemia / lymphoma, BCR-ABL1-like (provisional entity) (94), B-lymphoblastic leukemia / lymphoma, with iAMP21 (95), T-cell lymphoblastic leukemia / lymphoma: T-cell lymphoblastic leukemia / lymphoma (Precursor T-cell ALL) (196), Early T-cell precursor lymphoblastic leukemia (96),NK cell lymphoblastic leukemia / lymphoma: Natural killer (NK)- cell lymphoblastic leukemia / lymphoma (97) |
||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Did the recipient have a predisposing condition? | no,Unknown,yes | Did the recipient have a predisposing condition? | no,Unknown,yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Specify condition | Aplastic anemia,Bloom syndrome,Down Syndrome,Fanconi anemia,Other condition | Specify condition | Aplastic anemia,Bloom syndrome,Down Syndrome,Fanconi anemia,Other condition | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Specify other condition: | open text | Specify other condition: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Were tyrosine kinase inhibitors given for therapy at any time prior to the start of the preparative regimen / infusion? (e.g. imatinib mesylate, dasatinib, etc.) | no,yes | Were tyrosine kinase inhibitors given for therapy at any time prior to the start of the preparative regimen / infusion? (e.g. imatinib mesylate, dasatinib, etc.) | no,yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis) | no,Unknown,yes | Change/Clarification of Information Requested | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis or relapse) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were tests for molecular markers performed? (at diagnosis) | no,Unknown,yes | Change/Clarification of Information Requested | Were tests for molecular markers performed? (at diagnosis or relapse) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | BCR / ABL | Negative,Not Done,Positive | BCR / ABL | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | TEL-AML / AML1 | Negative,Not Done,Positive | TEL-AML / AML1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Other molecular marker | Negative,Not Done,Positive | Other molecular marker | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other molecular marker: | open text | Specify other molecular marker: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation) | no,Unknown,yes | Change/Clarification of Information Requested | Were cytogenetics tested (karyotyping or FISH)? (between diagnosis or at relapse and last evaluation) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis and last evaluation) | no,Unknown,yes | Change/Clarification of Information Requested | Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis or relapse and last evaluation) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | BCR / ABL | Negative,Not Done,Positive | BCR / ABL | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | TEL-AML / AML1 | Negative,Not Done,Positive | TEL-AML / AML1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Other molecular marker | Negative,Not Done,Positive | Other molecular marker | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other molecular marker: | open text | Specify other molecular marker: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (at last evaluation) | no,Unknown,yes | Were cytogenetics tested (karyotyping or FISH)? (at last evaluation) | no,Unknown,yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested via karyotyping? (at last evaluation) | No,Yes | Were cytogenetics tested via karyotyping? (at last evaluation) | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | Specify abnormalities (check all that apply) | (11q23) any abnormality,12p any abnormality,9p any abnormality,add(14q),del(12p) / 12p-,del(6q) / 6q-,del(9p) / 9p-,Hyperdiploid (> 50),Hypodiploid (< 46),iAMP21,-7,Other abnormality,t(1;19),t(10;14),t(11;14),t(12;21),t(2;8),t(4;11),t(5;14),t(8;14),t(8;22),t(9;22),+17,+21,+4,+8 | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were tests for molecular markers performed? (e.g. PCR, NGS) (at last evaluation) | no,Unknown,yes | Were tests for molecular markers performed? (e.g. PCR, NGS) (at last evaluation) | no,Unknown,yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | BCR / ABL | Negative,Not Done,Positive | BCR / ABL | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | TEL-AML / AML1 | Negative,Not Done,Positive | TEL-AML / AML1 | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Other molecular marker | Negative,Not Done,Positive | Other molecular marker | Negative,Not Done,Positive | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Specify other molecular marker: | open text | Specify other molecular marker: | open text | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion? | no,Unknown,yes | Did the recipient have central nervous system leukemia at any time prior to the start of the preparative regimen / infusion? | no,Unknown,yes | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | What was the disease status? | 1st complete remission (include CRi),1st relapse,2nd complete remission,2nd relapse, ≥ 3rd complete remission, ≥3rd relapse,No treatment,Primary induction failure | What was the disease status? | 1st complete remission (include CRi),1st relapse,2nd complete remission,2nd relapse, ≥ 3rd complete remission, ≥3rd relapse,No treatment,Primary induction failure | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | How many cycles of induction therapy were required to achieve 1st complete remission? | 1,2, ≥ 3 | How many cycles of induction therapy were required to achieve 1st complete remission? | 1,2, ≥ 3 | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Was the recipient in remission by flow cytometry? | Not applicable,No,Unknown,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Specify method(s) that was used to assess measurable residual disease status (check all that apply) | FISH, Karyotyping, Flow Cytometry, PCR, NGS, Not assessed | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by FISH? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by karyotyping assay? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Which leukemia phenotype was used for detection (check all the apply) | original leukemia immunophenotype, aberrant phenotype | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
What is the lower limit of detection (for the original leukemia immunophenotype) | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
What is the lower limit of detection (for the aberrant phenotype) | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by flow cytometry? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by PCR? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by NGS? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Date of most recent relapse: | YYYY/MM/DD | Date of most recent relapse: | YYYY/MM/DD | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms | yes | no | Specify acute leukemias of ambiguous lineage and other myeloid neoplasm classification | Acute undifferentiated leukemia,Blastic plasmacytoid dendritic cell neoplasm ,Mixed phenotype acute leukemia, B/myeloid, NOS,Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1,Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged,Mixed phenotype acute leukemia, T/myeloid, NOS,Other acute leukemia of ambiguous lineage or myeloid neoplasm | Specify acute leukemias of ambiguous lineage and other myeloid neoplasm classification | Acute undifferentiated leukemia,Blastic plasmacytoid dendritic cell neoplasm ,Mixed phenotype acute leukemia, B/myeloid, NOS,Mixed phenotype acute leukemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1,Mixed phenotype acute leukemia with t(v; 11q23.3); KMT2A rearranged,Mixed phenotype acute leukemia, T/myeloid, NOS,Other acute leukemia of ambiguous lineage or myeloid neoplasm | ||
| Disease Classification | Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms | yes | no | Specify other acute leukemia of ambiguous lineage or myeloid neoplasm: | open text | Specify other acute leukemia of ambiguous lineage or myeloid neoplasm: | open text | ||
| Disease Classification | Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms | yes | no | What was the disease status? (based on hematological test results) | 1st complete remission (no previous marrow or extramedullary relapse),1st relapse,2nd complete remission,2nd relapse, ≥ 3rd complete remission, ≥ 3rd relapse,No treatment,Primary induction failure | What was the disease status? (based on hematological test results) | 1st complete remission (no previous marrow or extramedullary relapse),1st relapse,2nd complete remission,2nd relapse, ≥ 3rd complete remission, ≥ 3rd relapse,No treatment,Primary induction failure | ||
| Disease Classification | Acute Leukemias of Ambiguous Lineage and Other Myeloid Neoplasms | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Was therapy given prior to this HCT? | no,yes | Was therapy given prior to this HCT? | no,yes | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Combination chemotherapy | no,yes | Combination chemotherapy | no,yes | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Hydroxyurea (Droxia, Hydrea) | no,yes | Hydroxyurea (Droxia, Hydrea) | no,yes | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib) | no,yes | Tyrosine kinase inhibitor (e.g.imatinib mesylate, dasatinib, nilotinib) | no,yes | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Interferon-α (Intron, Roferon) (includes PEG) | no,yes | Interferon-α (Intron, Roferon) (includes PEG) | no,yes | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Other therapy | no,yes | Other therapy | no,yes | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Specify other therapy: | open text | Specify other therapy: | open text | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | What was the disease status? | Accelerated phase,Blast phase,Complete hematologic response (CHR) preceded by accelerated phase and/or blast phase,Complete hematologic response (CHR) preceded only by chronic phase,Chronic phase | What was the disease status? | Accelerated phase,Blast phase,Complete hematologic response (CHR) preceded by accelerated phase and/or blast phase,Complete hematologic response (CHR) preceded only by chronic phase,Chronic phase | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Specify level of response | Complete cytogenetic response (CCyR),Complete molecular remission (CMR),Minimal cytogenetic response,Minor cytogenetic response,Major molecular remission (MMR),No cytogenetic response (No CyR),Partial cytogenetic response (PCyR) | Specify level of response | Complete cytogenetic response (CCyR),Complete molecular remission (CMR),Minimal cytogenetic response,Minor cytogenetic response,Major molecular remission (MMR),No cytogenetic response (No CyR),Partial cytogenetic response (PCyR) | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Number | 1st,2nd,3rd or higher | Number | 1st,2nd,3rd or higher | ||
| Disease Classification | Chronic Myelogenous Leukemia (CML) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | What was the MDS subtype at diagnosis? - If transformed to AML, indicate AML as primary disease; also complete AML Disease Classification questions | Atypical chronic myeloid leukemia (aCML), BCR-ABL1-,Chronic myelomonocytic leukemia (CMMoL),Juvenile myelomonocytic leukemia (JMML/JCML),Myelodysplastic syndrome with isolated del(5q),Myelodysplastic syndrome with multilineage dysplasia (MDS-MLD),MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T),Myelodysplastic syndrome / myeloproliferative neoplasm, unclassifiable, syndrome with single lineage dysplasia (MDS-SLD),Myelodysplastic syndrome (MDS), unclassifiable,Refractory cytopenia of childhood. Myelodysplatic Syndrome with excess blasts (MDS-EB): MDS with excess blasts-1 (MDS-EB-1),MDS with excess blasts-2 (MDS-EB-2). Myelodysplatic Syndrome with ring sideroblasts: MDS-RS with multilineage dysplasia (MDS-RS-MLD),MDS-RS with single lineage dysplasia (MDS-RS-SLD),Myelodysplastic | What was the MDS subtype at diagnosis? - If transformed to AML, indicate AML as primary disease; also complete AML Disease Classification questions | Atypical chronic myeloid leukemia (aCML), BCR-ABL1-,Chronic myelomonocytic leukemia (CMMoL),Juvenile myelomonocytic leukemia (JMML/JCML),Myelodysplastic syndrome with isolated del(5q),Myelodysplastic syndrome with multilineage dysplasia (MDS-MLD),MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T),Myelodysplastic syndrome / myeloproliferative neoplasm, unclassifiable, syndrome with single lineage dysplasia (MDS-SLD),Myelodysplastic syndrome (MDS), unclassifiable,Refractory cytopenia of childhood. Myelodysplatic Syndrome with excess blasts (MDS-EB): MDS with excess blasts-1 (MDS-EB-1),MDS with excess blasts-2 (MDS-EB-2). Myelodysplatic Syndrome with ring sideroblasts: MDS-RS with multilineage dysplasia (MDS-RS-MLD),MDS-RS with single lineage dysplasia (MDS-RS-SLD),Myelodysplastic | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Specify Myelodysplastic syndrome, unclassifiable (MDS-U) | MDS-U with 1% blood blasts,MDS-U based on defining cytogenetic abnormality,MDS-U with single lineage dysplasia and pancytopenia | Specify Myelodysplastic syndrome, unclassifiable (MDS-U) | MDS-U with 1% blood blasts,MDS-U based on defining cytogenetic abnormality,MDS-U with single lineage dysplasia and pancytopenia | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Was the disease MDS therapy related? | no,Unknown,yes | Was the disease MDS therapy related? | no,Unknown,yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Did the recipient have a predisposing condition? | no,Unknown,yes | Did the recipient have a predisposing condition? | no,Unknown,yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Specify condition | Aplastic anemia,DDX41-associated familial MDS,Fanconi anemia,GATA2 deficiency (including Emberger syndrome, MonoMac syndrome, DCML deficiency) ,Li-Fraumeni Syndrome,Other condition,Paroxysmal nocturnal hemoglobinuria,Diamond-Blackfan Anemia,RUNX1 deficiency (previously “familial platelet disorder with propensity to myeloid malignancies”) ,SAMD9- or SAMD9L-associated familial MDS,Shwachman-Diamond Syndrome,Telomere biology disorder (including dyskeratosis congenita) | Specify condition | Aplastic anemia,DDX41-associated familial MDS,Fanconi anemia,GATA2 deficiency (including Emberger syndrome, MonoMac syndrome, DCML deficiency) ,Li-Fraumeni Syndrome,Other condition,Paroxysmal nocturnal hemoglobinuria,Diamond-Blackfan Anemia,RUNX1 deficiency (previously “familial platelet disorder with propensity to myeloid malignancies”) ,SAMD9- or SAMD9L-associated familial MDS,Shwachman-Diamond Syndrome,Telomere biology disorder (including dyskeratosis congenita) | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Specify other condition: | open text | Specify other condition: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Date CBC drawn: | YYYY/MM/DD | Date CBC drawn: | YYYY/MM/DD | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | WBC | Known,Unknown | WBC | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | WBC | ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ● ___ x 106/L |
WBC | ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ● ___ x 106/L |
||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Neutrophils | Known,Unknown | Neutrophils | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Neutrophils | ___ ___% | Neutrophils | ___ ___% | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Blasts in blood | Known,Unknown | Blasts in blood | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Blasts in blood | ___ ___% | Blasts in blood | ___ ___% | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Hemoglobin | Known,Unknown | Hemoglobin | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | At Diagnosis: Hemoglobin | ___ ___ ___ ___ ● ___ ___ g/dL ___ ___ ___ ___ ● ___ ___ g/L ___ ___ ___ ___ ● ___ ___ mmol/L |
At Diagnosis: Hemoglobin | ___ ___ ___ ___ ● ___ ___ g/dL ___ ___ ___ ___ ● ___ ___ g/L ___ ___ ___ ___ ● ___ ___ mmol/L |
||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were RBCs transfused ≤ 30 days before date of test? | No,Yes | Were RBCs transfused ≤ 30 days before date of test? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Platelets | Known,Unknown | Platelets | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were platelets transfused ≤ 7 days before date of test? | No,Yes | Were platelets transfused ≤ 7 days before date of test? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were platelets transfused ≤ 7 days before date of test? | No,Yes | Were platelets transfused ≤ 7 days before date of test? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Blasts in bone marrow | Known,Unknown | Blasts in bone marrow | Known,Unknown | ||
| Disease Classification | yes | yes | Blasts in bone marrow | __ ___ ___% | Blasts in bone marrow | __ ___ ___% | |||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? | no,Unknown,yes | Were cytogenetics tested (karyotyping or FISH)? | no,Unknown,yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Sample source | Peripheral blood,Bone marrow | Sample source | Peripheral blood,Bone marrow | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,del(13q) / 13q-,i17q,inv(3),-13,-20,-5,-7,-Y,Other abnormality,t(1;3),t(11;16),t(2;11),t(3;21),t(3;3),t(6;9),+19,+8 | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,del(13q) / 13q-,i17q,inv(3),-13,-20,-5,-7,-Y,Other abnormality,t(1;3),t(11;16),t(2;11),t(3;21),t(3;3),t(6;9),+19,+8 | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Sample source | Peripheral blood,Bone marrow | Sample source | Peripheral blood,Bone marrow | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,del(13q) / 13q-,i17q,inv(3),-13,-20,-5,-7,-Y,Other abnormality,t(1;3),t(11;16),t(2;11),t(3;21),t(3;3),t(6;9),+19,+8 | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,del(13q) / 13q-,i17q,inv(3),-13,-20,-5,-7,-Y,Other abnormality,t(1;3),t(11;16),t(2;11),t(3;21),t(3;3),t(6;9),+19,+8 | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Did the recipient progress or transform to a different MDS subtype or AML between diagnosis and the start of the preparative regimen/ infusion? | No,Yes | Did the recipient progress or transform to a different MDS subtype or AML between diagnosis and the start of the preparative regimen/ infusion? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify the MDS subtype or AML after transformation | Transformed to AML,Chronic myelomonocytic leukemia (CMMoL),Myelodysplastic syndrome with isolated del(5q),Myelodysplastic syndrome with multilineage dysplasia (MDS-MLD),MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T),Myelodysplastic syndrome / myeloproliferative neoplasm, unclassifiable,Myelodysplastic syndrome with single lineage dysplasia (MDS-SLD),Myelodysplastic syndrome (MDS), unclassifiable,Refractory cytopenia of childhood. Myelodysplatic Syndrome with excess blasts (MDS-EB): MDS with excess blasts-1 (MDS-EB-1),MDS with excess blasts-2 (MDS-EB-2). Myelodysplatic syndrome with ring sideroblasts: MDS-RS with multilineage dysplasia (MDS-RS-MLD),MDS-RS with single lineage dysplasia (MDS-RS-SLD). | Specify the MDS subtype or AML after transformation | Transformed to AML,Chronic myelomonocytic leukemia (CMMoL),Myelodysplastic syndrome with isolated del(5q),Myelodysplastic syndrome with multilineage dysplasia (MDS-MLD),MDS / MPN with ring sideroblasts and thrombocytosis (MDS / MPN-RS-T),Myelodysplastic syndrome / myeloproliferative neoplasm, unclassifiable,Myelodysplastic syndrome with single lineage dysplasia (MDS-SLD),Myelodysplastic syndrome (MDS), unclassifiable,Refractory cytopenia of childhood. Myelodysplatic Syndrome with excess blasts (MDS-EB): MDS with excess blasts-1 (MDS-EB-1),MDS with excess blasts-2 (MDS-EB-2). Myelodysplatic syndrome with ring sideroblasts: MDS-RS with multilineage dysplasia (MDS-RS-MLD),MDS-RS with single lineage dysplasia (MDS-RS-SLD). | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify Myelodysplastic syndrome, unclassifiable (MDS-U) | MDS-U with 1% blood blasts,MDS-U based on defining cytogenetic abnormality,MDS-U with single lineage dysplasia and pancytopenia | Specify Myelodysplastic syndrome, unclassifiable (MDS-U) | MDS-U with 1% blood blasts,MDS-U based on defining cytogenetic abnormality,MDS-U with single lineage dysplasia and pancytopenia | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify the date of the most recent transformation: | YYYY/MM/DD | Specify the date of the most recent transformation: | YYYY/MM/DD | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Date of MDS diagnosis: | YYYY/MM/DD | Date of MDS diagnosis: | YYYY/MM/DD | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Date CBC drawn: | YYYY/MM/DD | Date CBC drawn: | YYYY/MM/DD | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | WBC | Known,Unknown | WBC | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Neutrophils | Known,Unknown | Neutrophils | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Neutrophils | ___ ___% | Neutrophils | ___ ___% | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Blasts in blood | Known,Unknown | Blasts in blood | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Blasts in blood | ___ ___% | Blasts in blood | ___ ___% | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Hemoglobin | Known,Unknown | Hemoglobin | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Prior to Infusion: Hemoglobin | ___ ___ ___ ___ ● ___ ___ g/dL ___ ___ ___ ___ ● ___ ___ g/L ___ ___ ___ ___ ● ___ ___ mmol/L |
Prior to Infusion: Hemoglobin | ___ ___ ___ ___ ● ___ ___ g/dL ___ ___ ___ ___ ● ___ ___ g/L ___ ___ ___ ___ ● ___ ___ mmol/L |
||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were RBCs transfused ≤ 30 days before date of test? | No,Yes | Were RBCs transfused ≤ 30 days before date of test? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Platelets | Known,Unknown | Platelets | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Platelets | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ ___ x 106/L |
Platelets | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ ___ x 106/L |
||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Platelets | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ ___ x 106/L |
Platelets | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ ___ x 106/L |
||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Blasts in bone marrow | Known,Unknown | Blasts in bone marrow | Known,Unknown | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Blasts in bone marrow | __ ___ ___% | Blasts in bone marrow | __ ___ ___% | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? | no,Unknown,yes | Were cytogenetics tested (karyotyping or FISH)? | no,Unknown,yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Sample source | Peripheral blood,Bone marrow | Sample source | Peripheral blood,Bone marrow | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,del(13q) / 13q-,i17q,inv(3),-13,-20,-5,-7,-Y,Other abnormality,t(1;3),t(11;16),t(2;11),t(3;21),t(3;3),t(6;9),+19,+8 | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,del(13q) / 13q-,i17q,inv(3),-13,-20,-5,-7,-Y,Other abnormality,t(1;3),t(11;16),t(2;11),t(3;21),t(3;3),t(6;9),+19,+8 | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Sample source | Peripheral blood,Bone marrow | Sample source | Peripheral blood,Bone marrow | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,del(13q) / 13q-,i17q,inv(3),-13,-20,-5,-7,-Y,Other abnormality,t(1;3),t(11;16),t(2;11),t(3;21),t(3;3),t(6;9),+19,+8 | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(3q) / 3q-,del(5q) / 5q-,del(7q) / 7q-,del(9q) / 9q-,del(13q) / 13q-,i17q,inv(3),-13,-20,-5,-7,-Y,Other abnormality,t(1;3),t(11;16),t(2;11),t(3;21),t(3;3),t(6;9),+19,+8 | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. cytogenetic or FISH report) | No,Yes | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | What was the disease status? | Complete remission (CR),Hematologic improvement (HI),Not assessed,No response (NR) / stable disease (SD),Progression from hematologic improvement (Prog from HI),Relapse from complete remission (Rel from CR) | What was the disease status? | Complete remission (CR),Hematologic improvement (HI),Not assessed,No response (NR) / stable disease (SD),Progression from hematologic improvement (Prog from HI),Relapse from complete remission (Rel from CR) | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Specify the cell line examined to determine HI status | HI-E,HI-N,HI-P | Change/Clarification of Information Requested | Specify the cell lines examined to determine HI status | HI-E,HI-N,HI-P | Examples added or typographical errors corrected for clarification |
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Specify transfusion dependence | Low-transfusion burden (LTB),Non-transfused (NTD) | Specify transfusion dependence | Low-transfusion burden (LTB),Non-transfused (NTD) | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | What was the MPN subtype at diagnosis? | Chronic eosinophilic leukemia, not otherwise specified (NOS),Primary myelofibrosis (PMF),Chronic neutrophilic leukemia,,Essential thrombocythemia,Myeloproliferative neoplasm (MPN), unclassifiable,Myeloid / lymphoid neoplasms with FGFR1 rearrangement,Myeloid / lymphoid neoplasms with PCM1-JAK2,Myeloid / lymphoid neoplasms with PDGFRA rearrangement,Myeloid / lymphoid neoplasms with PDGFRB rearrangement,Polycythemia vera (PCV),Mastocytosis: Cutaneous mastocytosis (CM), Systemic mastocytosis, Mast cell sarcoma (MCS) | What was the MPN subtype at diagnosis? | Chronic eosinophilic leukemia, not otherwise specified (NOS),Primary myelofibrosis (PMF),Chronic neutrophilic leukemia,,Essential thrombocythemia,Myeloproliferative neoplasm (MPN), unclassifiable,Myeloid / lymphoid neoplasms with FGFR1 rearrangement,Myeloid / lymphoid neoplasms with PCM1-JAK2,Myeloid / lymphoid neoplasms with PDGFRA rearrangement,Myeloid / lymphoid neoplasms with PDGFRB rearrangement,Polycythemia vera (PCV),Mastocytosis: Cutaneous mastocytosis (CM), Systemic mastocytosis, Mast cell sarcoma (MCS) | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify systemic mastocytosis | Aggressive systemic mastocytosis (ASM),Indolent systemic mastocytosis (ISM),Mast cell leukemia (MCL),Systemic mastocytosis with an associated hematological neoplasm (SM-AHN),Smoldering systemic mastocytosis (SSM) | Specify systemic mastocytosis | Aggressive systemic mastocytosis (ASM),Indolent systemic mastocytosis (ISM),Mast cell leukemia (MCL),Systemic mastocytosis with an associated hematological neoplasm (SM-AHN),Smoldering systemic mastocytosis (SSM) | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Was documentation submitted to the CIBMTR? (e.g. pathology report used for diagnosis) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. pathology report used for diagnosis) | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Did the recipient have constitutional symptoms in six months before diagnosis? (symptoms are >10% weight loss in 6 months, night sweats, or unexplained fever higher than 37.5 °C) | No,Unknown,Yes | Did the recipient have constitutional symptoms in six months before diagnosis? (symptoms are >10% weight loss in 6 months, night sweats, or unexplained fever higher than 37.5 °C) | No,Unknown,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Date CBC drawn: | YYYY/MM/DD | Date CBC drawn: | YYYY/MM/DD | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | WBC | Known,Unknown | WBC | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | WBC | ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ● ___ x 106/L |
WBC | ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ● ___ x 106/L |
||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Neutrophils | Known,Unknown | Neutrophils | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Neutrophils | ___ ___% | Neutrophils | ___ ___% | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Blasts in blood | Known,Unknown | Blasts in blood | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Blasts in blood | ___ ___% | Blasts in blood | ___ ___% | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Hemoglobin | Known,Unknown | Hemoglobin | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Hemoglobin | ___ ___ ___ ___ ● ___ ___ g/dL ___ ___ ___ ___ ● ___ ___ g/L ___ ___ ___ ___ ● ___ ___ mmol/L |
Hemoglobin | ___ ___ ___ ___ ● ___ ___ g/dL ___ ___ ___ ___ ● ___ ___ g/L ___ ___ ___ ___ ● ___ ___ mmol/L |
||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were RBCs transfused ≤ 30 days before date of test? | No,Yes | Were RBCs transfused ≤ 30 days before date of test? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Platelets | Known,Unknown | Platelets | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Platelets | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ ___ x 106/L |
Platelets | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ ___ x 106/L |
||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were platelets transfused ≤ 7 days before date of test? | No,Yes | Were platelets transfused ≤ 7 days before date of test? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Blasts in bone marrow | Known,Unknown | Blasts in bone marrow | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Blasts in bone marrow | __ ___ ___% | Blasts in bone marrow | __ ___ ___% | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were tests for driver mutations performed? | No,Unknown,Yes | Were tests for driver mutations performed? | No,Unknown,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | JAK2 | Negative,Not done,Positive | JAK2 | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | JAK2 V617F | Negative,Not done,Positive | JAK2 V617F | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | JAK2 Exon 12 | Negative,Not done,Positive | JAK2 Exon 12 | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | CALR | Negative,Not done,Positive | CALR | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | CALR type 1 | Negative,Not done,Positive | CALR type 1 | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | CALR type 2 | Negative,Not done,Positive | CALR type 2 | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Not defined | Negative,Not done,Positive | Not defined | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | MPL | Negative,Not done,Positive | MPL | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | CSF3R | Negative,Not done,Positive | CSF3R | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Was documentation submitted to the CIBMTR? | No,Yes | Was documentation submitted to the CIBMTR? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? | no,Unknown,yes | Were cytogenetics tested (karyotyping or FISH)? | no,Unknown,yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Sample source | Peripheral blood,Bone marrow | Sample source | Peripheral blood,Bone marrow | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(5q) / 5q-,del(7q) / 7q-,del(13q) / 13q-,dup(1),i17q,inv(3),-5,-7,-Y,Other abnormality,t(1;any),t(11q23;any),t(12p11.2;any),t(3q21;any),t(6;9),+8,+9 | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(5q) / 5q-,del(7q) / 7q-,del(13q) / 13q-,dup(1),i17q,inv(3),-5,-7,-Y,Other abnormality,t(1;any),t(11q23;any),t(12p11.2;any),t(3q21;any),t(6;9),+8,+9 | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. FISH report) | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Sample source | Peripheral blood,Bone marrow | Sample source | Peripheral blood,Bone marrow | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(5q) / 5q-,del(7q) / 7q-,del(13q) / 13q-,dup(1),i17q,inv(3),-5,-7,-Y,Other abnormality,t(1;any),t(11q23;any),t(12p11.2;any),t(3q21;any),t(6;9),+8,+9 | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(5q) / 5q-,del(7q) / 7q-,del(13q) / 13q-,dup(1),i17q,inv(3),-5,-7,-Y,Other abnormality,t(1;any),t(11q23;any),t(12p11.2;any),t(3q21;any),t(6;9),+8,+9 | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. karyotyping report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. karyotyping report) | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Did the recipient progress or transform to a different MPN subtype or AML between diagnosis and the start of the preparative regimen / infusion? | No,Yes | Did the recipient progress or transform to a different MPN subtype or AML between diagnosis and the start of the preparative regimen / infusion? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the MPN subtype or AML after transformation | Transformed to AML,Post-essential thrombocythemic myelofibrosis,Post-polycythemic myelofibrosis | Specify the MPN subtype or AML after transformation | Transformed to AML,Post-essential thrombocythemic myelofibrosis,Post-polycythemic myelofibrosis | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the date of the most recent transformation: | YYYY/MM/DD | Specify the date of the most recent transformation: | YYYY/MM/DD | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Date of MPN diagnosis: | YYYY/MM/DD | Date of MPN diagnosis: | YYYY/MM/DD | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify transfusion dependence at last evaluation prior to the start of the preparative regimen / infusion | High-transfusion burden (HTB)- (≥ 8 RBCs in 16weeks; ≥ 4 in 8 weeks),Low-transfusion burden (LTB)-(3-7 RBCs in 16 weeks in at least 2 transfusion episodes; maximum of 3 in 8 weeks),Non-transfused (NTD) –(0 RBCs in 16 weeks) | Specify transfusion dependence at last evaluation prior to the start of the preparative regimen / infusion | High-transfusion burden (HTB)- (≥ 8 RBCs in 16weeks; ≥ 4 in 8 weeks),Low-transfusion burden (LTB)-(3-7 RBCs in 16 weeks in at least 2 transfusion episodes; maximum of 3 in 8 weeks),Non-transfused (NTD) –(0 RBCs in 16 weeks) | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Did the recipient have constitutional symptoms in six months before last evaluation prior to the start of the preparative regimen / infusion? (symptoms are >10% weight loss in 6 months, night sweats, or unexplained fever higher than 37.5 °C) | No,Unknown,Yes | Did the recipient have constitutional symptoms in six months before last evaluation prior to the start of the preparative regimen / infusion? (symptoms are >10% weight loss in 6 months, night sweats, or unexplained fever higher than 37.5 °C) | No,Unknown,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Did the recipient have splenomegaly at last evaluation prior to the start of the preparative regimen / infusion? | No,Not applicable(splenectomy) ,Unknown,Yes | Did the recipient have splenomegaly at last evaluation prior to the start of the preparative regimen / infusion? | No,Not applicable(splenectomy) ,Unknown,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the method used to measure spleen size | CT/MRI scan,Physical exam,Ultrasound | Specify the method used to measure spleen size | CT/MRI scan,Physical exam,Ultrasound | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the spleen size: | : ___ ___ centimeters below left costal margin | Specify the spleen size: | : ___ ___ centimeters below left costal margin | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the spleen size: | :___ ___ centimeters | Specify the spleen size: | :___ ___ centimeters | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Did the recipient have hepatomegaly at last evaluation prior to the start of the preparative regimen / infusion? | no,Unknown,yes | Did the recipient have hepatomegaly at last evaluation prior to the start of the preparative regimen / infusion? | no,Unknown,yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the method used to measure liver size | CT/MRI scan,Physical exam,Ultrasound | Specify the method used to measure liver size | CT/MRI scan,Physical exam,Ultrasound | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the liver size: | : ___ ___ centimeters below right costal margin | Specify the liver size: | : ___ ___ centimeters below right costal margin | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the liver size: | : ___ ___ centimeters | Specify the liver size: | : ___ ___ centimeters | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Date CBC drawn: | YYYY/MM/DD | Date CBC drawn: | YYYY/MM/DD | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | WBC | Known,Unknown | WBC | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | WBC | ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ● ___ x 106/L |
WBC | ___ ___ ___ ___ ___ ___ ● ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ● ___ x 106/L |
||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Neutrophils | Known,Unknown | Neutrophils | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Neutrophils | ___ ___% | Neutrophils | ___ ___% | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Blasts in blood | Known,Unknown | Blasts in blood | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Blasts in blood | ___ ___% | Blasts in blood | ___ ___% | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Hemoglobin | Known,Unknown | Hemoglobin | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Hemoglobin | ___ ___ ___ ___ ● ___ ___ g/dL ___ ___ ___ ___ ● ___ ___ g/L ___ ___ ___ ___ ● ___ ___ mmol/L |
Hemoglobin | ___ ___ ___ ___ ● ___ ___ g/dL ___ ___ ___ ___ ● ___ ___ g/L ___ ___ ___ ___ ● ___ ___ mmol/L |
||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were RBCs transfused ≤ 30 days before date of test? | No,Yes | Were RBCs transfused ≤ 30 days before date of test? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Platelets | Known,Unknown | Platelets | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Platelets | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ ___ x 106/L |
Platelets | ___ ___ ___ ___ ___ ___ ___ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ ___ ___ ___ x 106/L |
||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were platelets transfused ≤ 7 days before date of test? | No,Yes | Were platelets transfused ≤ 7 days before date of test? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Blasts in bone marrow | Known,Unknown | Blasts in bone marrow | Known,Unknown | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Blasts in bone marrow | __ ___ ___% | Blasts in bone marrow | __ ___ ___% | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were tests for driver mutations performed? | No,Unknown,Yes | Were tests for driver mutations performed? | No,Unknown,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | JAK2 | Negative,Not done,Positive | JAK2 | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | JAK2 V617F | Negative,Not done,Positive | JAK2 V617F | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | JAK2 Exon 12 | Negative,Not done,Positive | JAK2 Exon 12 | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | CALR | Negative,Not done,Positive | CALR | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | CALR type 1 | Negative,Not done,Positive | CALR type 1 | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | CALR type 2 | Negative,Not done,Positive | CALR type 2 | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Not defined | Negative,Not done,Positive | Not defined | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | MPL | Negative,Not done,Positive | MPL | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | CSF3R | Negative,Not done,Positive | CSF3R | Negative,Not done,Positive | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Was documentation submitted to the CIBMTR? | No,Yes | Was documentation submitted to the CIBMTR? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? | no,Unknown,yes | Were cytogenetics tested (karyotyping or FISH)? | no,Unknown,yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Sample source | Peripheral blood,Bone marrow | Sample source | Peripheral blood,Bone marrow | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(5q) / 5q-,del(7q) / 7q-,del(13q) / 13q-,dup(1),i17q,inv(3),-5,-7,-Y,Other abnormality,t(1;any),t(11q23;any),t(12p11.2;any),t(3q21;any),t(6;9),+8,+9 | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(5q) / 5q-,del(7q) / 7q-,del(13q) / 13q-,dup(1),i17q,inv(3),-5,-7,-Y,Other abnormality,t(1;any),t(11q23;any),t(12p11.2;any),t(3q21;any),t(6;9),+8,+9 | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. FISH report) | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Sample source | Peripheral blood,Bone marrow | Sample source | Peripheral blood,Bone marrow | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | Specify number of distinct cytogenetic abnormalities | Four or more (4 or more),One (1),Three (3),Two (2) | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(5q) / 5q-,del(7q) / 7q-,del(13q) / 13q-,dup(1),i17q,inv(3),-5,-7,-Y,Other abnormality,t(1;any),t(11q23;any),t(12p11.2;any),t(3q21;any),t(6;9),+8,+9 | Specify abnormalities (check all that apply) | del(11q) / 11q-,del(12p) / 12p-,del(20q) / 20q-,del(5q) / 5q-,del(7q) / 7q-,del(13q) / 13q-,dup(1),i17q,inv(3),-5,-7,-Y,Other abnormality,t(1;any),t(11q23;any),t(12p11.2;any),t(3q21;any),t(6;9),+8,+9 | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | yes | Was documentation submitted to the CIBMTR? (e.g. karyotyping report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. karyotyping report) | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | What was the disease status? | Clinical improvement (CI),Complete clinical remission (CR),Not assessed,Partial clinical remission (PR),Progressive disease,Relapse,Stable disease (SD) | What was the disease status? | Clinical improvement (CI),Complete clinical remission (CR),Not assessed,Partial clinical remission (PR),Progressive disease,Relapse,Stable disease (SD) | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Was an anemia response achieved? | No,Yes | Was an anemia response achieved? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Was a spleen response achieved? | No,Yes | Was a spleen response achieved? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Was a symptom response achieved? | No,Yes | Was a symptom response achieved? | No,Yes | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the cytogenetic response | Complete response (CR Eradication of pre-existing abnormality,Not assessed,Not applicable,None of the above: Does not meet the CR or PR criteria, Partial response (PR) ≥ 50% reduction in abnormal metaphases ,Re-emergence of pre-existing cytogenetic abnormality | Specify the cytogenetic response | Complete response (CR Eradication of pre-existing abnormality,Not assessed,Not applicable,None of the above: Does not meet the CR or PR criteria, Partial response (PR) ≥ 50% reduction in abnormal metaphases ,Re-emergence of pre-existing cytogenetic abnormality | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Specify the molecular response | Complete response (CR): Eradication of pre-existing abnormality ,Not assessed,Not applicable,None of the above: Does not meet the CR or PR criteria ,Partial response (PR): ≥50% decrease in allele burden ,Re-emergence of a pre-existing molecular abnormality | Specify the molecular response | Complete response (CR): Eradication of pre-existing abnormality ,Not assessed,Not applicable,None of the above: Does not meet the CR or PR criteria ,Partial response (PR): ≥50% decrease in allele burden ,Re-emergence of a pre-existing molecular abnormality | ||
| Disease Classification | Myeloproliferative Neoplasms (MPN) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Other Leukemia (OL) | yes | no | Specify the other leukemia classification | Chronic lymphocytic leukemia (CLL), NOS,Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL),Hairy cell leukemia,Hairy cell leukemia variant,Monoclonal B-cell lymphocytosis,Other leukemia,Other leukemia, NOS,PLL, B-cell,Prolymphocytic leukemia (PLL), NOS,PLL, T-cell | Specify the other leukemia classification | Chronic lymphocytic leukemia (CLL), NOS,Chronic lymphocytic leukemia (CLL), B-cell / small lymphocytic lymphoma (SLL),Hairy cell leukemia,Hairy cell leukemia variant,Monoclonal B-cell lymphocytosis,Other leukemia,Other leukemia, NOS,PLL, B-cell,Prolymphocytic leukemia (PLL), NOS,PLL, T-cell | ||
| Disease Classification | Other Leukemia (OL) | yes | no | Specify other leukemia: | open text | Specify other leukemia: | open text | ||
| Disease Classification | Other Leukemia (OL) | yes | no | Was any 17p abnormality detected? | no,yes | Was any 17p abnormality detected? | no,yes | ||
| Disease Classification | Other Leukemia (OL) | yes | no | Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any time after CLL diagnosis? | no,yes | Did a histologic transformation to diffuse large B-cell lymphoma (Richter syndrome) occur at any time after CLL diagnosis? | no,yes | ||
| Disease Classification | Other Leukemia (OL) | yes | no | What was the disease status? (Atypical CML) | 1st complete remission (no previous bone marrow or extramedullary relapse),1st relapse,2nd complete remission,2nd relapse,≥3rd complete remission,≥3rd relapse,No treatment,Primary induction failure | What was the disease status? (Atypical CML) | 1st complete remission (no previous bone marrow or extramedullary relapse),1st relapse,2nd complete remission,2nd relapse,≥3rd complete remission,≥3rd relapse,No treatment,Primary induction failure | ||
| Disease Classification | Other Leukemia (OL) | yes | no | What was the disease status? (CLL, PLL, Hairy cell leukemia, Other leukemia) | Complete remission (CR),Not assessed,Untreated,Partial remission (PR),Progressive disease (Prog),Stable disease (SD) | What was the disease status? (CLL, PLL, Hairy cell leukemia, Other leukemia) | Complete remission (CR),Not assessed,Untreated,Partial remission (PR),Progressive disease (Prog),Stable disease (SD) | ||
| Disease Classification | Other Leukemia (OL) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Specify the lymphoma histology | Hodgkin Lymphoma 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 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- Activated B-cell type (non-GCB) (1821) Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) Diffuse large B-cell Lymphoma (cell of origin unknown) (107) 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, 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, predominantly small cleaved cell (Grade I follicle center lymphoma) (102) 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 DLBCL, leg type (1822) Primary cutaneous follicle center lymphoma (1817) Primary diffuse, large B-cell lymphoma of the CNS (118) Primary effusion lymphoma (138) Primary mediastinal (thymic) large B-cell lymphoma (125) Splenic B-cell lymphoma/leukemia, unclassifiable (1811) Splenic diffuse red pulp small B-cell lymphoma (1812) Splenic marginal zone B-cell lymphoma (124) T-cell / histiocytic rich large B-cell lymphoma (120) Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173) Other B-cell lymphoma (129) – Go to question 380 T-cell and NK-cell Neoplasms Adult T-cell lymphoma / leukemia (HTLV1 associated) (134) Aggressive NK-cell leukemia (27) Anaplastic large-cell lymphoma (ALCL), ALK positive (143) Anaplastic large-cell lymphoma (ALCL), ALK negative (144) Angioimmunoblastic T-cell lymphoma (131) Breast implant–associated anaplastic large-cell lymphoma (1861) Chronic lymphoproliferative disorder of NK cells (1856) Enteropathy-type T-cell lymphoma (133) Extranodal NK / T-cell lymphoma, nasal type (137) 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 acral CD8+ T-cell lymphoma (1853) Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (1854) Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1852) Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell lymphoma (C-ALCL), lymphoid papulosis] (147) Primary cutaneous γδ T-cell lymphoma (1851) 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) 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) |
Change/Clarification of Response Options | Specify the lymphoma histology | Classical Hodgkin Lymphoma Lymphocyte depleted (154) Lymphocyte-rich (151) Mixed cellularity (153) Nodular sclerosis (152) Other Classical Hodgkin Lymphoma Hodgkin lymphoma, not otherwise specified (150) Nodular lymphocyte predominant Hodgkin lymphoma Non-Hodgkin Lymphoma 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- Activated B-cell type (non-GCB) (1821) Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) Diffuse large B-cell Lymphoma (cell of origin unknown) (107) 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, 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, predominantly small cleaved cell (Grade I follicle center lymphoma) (102) 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 DLBCL, leg type (1822) Primary cutaneous follicle center lymphoma (1817) Primary diffuse, large B-cell lymphoma of the CNS (118) Primary effusion lymphoma (138) Primary mediastinal (thymic) large B-cell lymphoma (125) Splenic B-cell lymphoma/leukemia, unclassifiable (1811) Splenic diffuse red pulp small B-cell lymphoma (1812) Splenic marginal zone B-cell lymphoma (124) T-cell / histiocytic rich large B-cell lymphoma (120) Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173) Other B-cell lymphoma (129) – Go to question 380 T-cell and NK-cell Neoplasms Adult T-cell lymphoma / leukemia (HTLV1 associated) (134) Aggressive NK-cell leukemia (27) Anaplastic large-cell lymphoma (ALCL), ALK positive (143) Anaplastic large-cell lymphoma (ALCL), ALK negative (144) Angioimmunoblastic T-cell lymphoma (131) Breast implant–associated anaplastic large-cell lymphoma (1861) Chronic lymphoproliferative disorder of NK cells (1856) Enteropathy-type T-cell lymphoma (133) Extranodal NK / T-cell lymphoma, nasal type (137) 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 acral CD8+ T-cell lymphoma (1853) Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (1854) Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1852) Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell lymphoma (C-ALCL), lymphoid papulosis] (147) Primary cutaneous γδ T-cell lymphoma (1851) 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) 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) |
Be consistent with current clinical landscape, improve transplant outcome data |
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Specify other lymphoma histology: | open text | Specify other lymphoma histology: | open text | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Assignment of DLBCL (germinal center B-cell type vs. activated B-cell type) subtype was based on | Gene expression profile,Immunohistochemistry (e.g. Han’s algorithm),Unknown | Assignment of DLBCL (germinal center B-cell type vs. activated B-cell type) subtype was based on | Gene expression profile,Immunohistochemistry (e.g. Han’s algorithm),Unknown | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Is the lymphoma histology reported at transplant a transformation from CLL? | no,yes | Change/Clarification of Response Options | Is the lymphoma histology reported at transplant a transformation from CLL? | no,yes (Also complete Chronic Lymphocytic Leukemia (CLL) ) | Capture additional relevent disease information |
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Was any 17p abnormality detected? | no,yes | Was any 17p abnormality detected? | no,yes | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Is the lymphoma histology reported at transplant a transformation from a different lymphoma histology? (Not CLL) | No,Yes | Is the lymphoma histology reported at transplant a transformation from a different lymphoma histology? (Not CLL) | No,Yes | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Specify the original lymphoma histology (prior to transformation) | Aggressive NK-cell leukemia,Anaplastic large-cell lymphoma (ALCL), ALK negative,Anaplastic large-cell lymphoma (ALCL), ALK positive,Angioimmunoblastic T-cell lymphoma,Adult T-cell lymphoma / leukemia (HTLV1 associated),Breast implant-associated anaplastic large-cell lymphoma,Burkitt-like lymphoma with 11q aberration,Chronic lymphoproliferative disorder of NK cells,Diffuse, Large B-cell Lymphoma (cell of origin unknown),B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin Lymphoma,DLBCL associated with chronic inflammation,EBV+ DLBCL, NOS,Diffuse, large B-cell lymphoma- Germinal center B-cell type,HHV8+ DLBCL, NOS,Diffuse, large B-cell lymphoma- Activated B-cell type (non-GCB),EBV+ mucocutaneous ulcer,Enteropathy-type T-cell lymphoma,Extranodal NK / T-cell lymphoma, nasal type,Duodenal-type follicular lymphoma,Pediatric-type follicular lymphoma,Follicular T-cell lymphoma,Follicular (grade unknown),Follicular, predominantly large cell (Grade IIIA follicle center lymphoma),Follicular, predominantly large cell (Grade IIIB follicle center lymphoma),Follicular, predominantly large cell (Grade IIIA vs IIIB not specified),Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma),Follicular, mixed, small cleaved and large cell (Grade II follicle center lymphoma),Hepatosplenic T-cell lymphoma,High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements,High-grade B-cell lymphoma, NOS,Hodgkin lymphoma, not otherwise specified,Infectious mononucleosis PTLD,Intravascular large B-cell lymphoma,Indolent T-cell lymphoproliferative disorder of the GI tract,ALK+ large B-cell lymphoma,Large B-cell lymphoma with IRF4 rearrangement,Lymphocyte depleted,Lymphocyte-rich,Lymphomatoid granulomatosis,Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT),Mixed cellularity,Primary mediastinal (thymic) large B-cell lymphoma,Monomorphic epitheliotropic intestinal T-cell lymphoma,Mycosis fungoides,Mantle cell lymphoma,Nodular lymphocyte predominant Hodgkin lymphoma,Nodal marginal zone B-cell lymphoma (± monocytoid B-cells),Nodal peripheral T-cell lymphoma with TFH phenotype,Nodular sclerosis,Other T-cell / NK-cell lymphoma,Other B-cell lymphoma,Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma,Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell lymphoma (C-ALCL), lymphoid papulosis],Primary cutaneous acral CD8+ T-cell lymphoma,Primary cutaneous CD4+ small / medium T-cell lymphoproliferative disorder,Primary cutaneous follicle center lymphoma,Primary cutaneous gamma-delta T-cell lymphoma,Primary diffuse, large B-cell lymphoma of the CNS,Primary cutaneous DLBCL, leg type,Pediatric nodal marginal zone lymphoma,Plasmacytic hyperplasia PTLD,Plasmablastic lymphoma,Primary effusion lymphoma,Peripheral T-cell lymphoma (PTCL), NOS,Florid follicular hyperplasia PTLD,Classical Hodgkin lymphoma PTLD,Monomorphic PTLD (B- and T-/NK-cell types),Polymorphic PTLD,Splenic B-cell lymphoma / leukemia, unclassifiable,Splenic diffuse red pulp small B-cell lymphoma,Splenic marginal zone B-cell lymphoma,Burkitt lymphoma,Subcutaneous panniculitis-like T-cell lymphoma,Systemic EBV+ T-cell lymphoma of childhood,Sezary syndrome,T-cell / histiocytic rich large B-cell lymphoma,T-cell large granular lymphocytic leukemia,Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma | Specify the original lymphoma histology (prior to transformation) | Aggressive NK-cell leukemia,Anaplastic large-cell lymphoma (ALCL), ALK negative,Anaplastic large-cell lymphoma (ALCL), ALK positive,Angioimmunoblastic T-cell lymphoma,Adult T-cell lymphoma / leukemia (HTLV1 associated),Breast implant-associated anaplastic large-cell lymphoma,Burkitt-like lymphoma with 11q aberration,Chronic lymphoproliferative disorder of NK cells,Diffuse, Large B-cell Lymphoma (cell of origin unknown),B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and classical Hodgkin Lymphoma,DLBCL associated with chronic inflammation,EBV+ DLBCL, NOS,Diffuse, large B-cell lymphoma- Germinal center B-cell type,HHV8+ DLBCL, NOS,Diffuse, large B-cell lymphoma- Activated B-cell type (non-GCB),EBV+ mucocutaneous ulcer,Enteropathy-type T-cell lymphoma,Extranodal NK / T-cell lymphoma, nasal type,Duodenal-type follicular lymphoma,Pediatric-type follicular lymphoma,Follicular T-cell lymphoma,Follicular (grade unknown),Follicular, predominantly large cell (Grade IIIA follicle center lymphoma),Follicular, predominantly large cell (Grade IIIB follicle center lymphoma),Follicular, predominantly large cell (Grade IIIA vs IIIB not specified),Follicular, predominantly small cleaved cell (Grade I follicle center lymphoma),Follicular, mixed, small cleaved and large cell (Grade II follicle center lymphoma),Hepatosplenic T-cell lymphoma,High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements,High-grade B-cell lymphoma, NOS,Hodgkin lymphoma, not otherwise specified,Infectious mononucleosis PTLD,Intravascular large B-cell lymphoma,Indolent T-cell lymphoproliferative disorder of the GI tract,ALK+ large B-cell lymphoma,Large B-cell lymphoma with IRF4 rearrangement,Lymphocyte depleted,Lymphocyte-rich,Lymphomatoid granulomatosis,Extranodal marginal zone B-cell lymphoma of mucosal associated lymphoid tissue type (MALT),Mixed cellularity,Primary mediastinal (thymic) large B-cell lymphoma,Monomorphic epitheliotropic intestinal T-cell lymphoma,Mycosis fungoides,Mantle cell lymphoma,Nodular lymphocyte predominant Hodgkin lymphoma,Nodal marginal zone B-cell lymphoma (± monocytoid B-cells),Nodal peripheral T-cell lymphoma with TFH phenotype,Nodular sclerosis,Other T-cell / NK-cell lymphoma,Other B-cell lymphoma,Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma,Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell lymphoma (C-ALCL), lymphoid papulosis],Primary cutaneous acral CD8+ T-cell lymphoma,Primary cutaneous CD4+ small / medium T-cell lymphoproliferative disorder,Primary cutaneous follicle center lymphoma,Primary cutaneous gamma-delta T-cell lymphoma,Primary diffuse, large B-cell lymphoma of the CNS,Primary cutaneous DLBCL, leg type,Pediatric nodal marginal zone lymphoma,Plasmacytic hyperplasia PTLD,Plasmablastic lymphoma,Primary effusion lymphoma,Peripheral T-cell lymphoma (PTCL), NOS,Florid follicular hyperplasia PTLD,Classical Hodgkin lymphoma PTLD,Monomorphic PTLD (B- and T-/NK-cell types),Polymorphic PTLD,Splenic B-cell lymphoma / leukemia, unclassifiable,Splenic diffuse red pulp small B-cell lymphoma,Splenic marginal zone B-cell lymphoma,Burkitt lymphoma,Subcutaneous panniculitis-like T-cell lymphoma,Systemic EBV+ T-cell lymphoma of childhood,Sezary syndrome,T-cell / histiocytic rich large B-cell lymphoma,T-cell large granular lymphocytic leukemia,Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Specify other lymphoma histology: | open text | Specify other lymphoma histology: | open text | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Date of original lymphoma diagnosis: (report the date of diagnosis of original lymphoma subtype) | YYYY/MM/DD | Date of original lymphoma diagnosis: (report the date of diagnosis of original lymphoma subtype) | YYYY/MM/DD | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Was a PET (or PET/CT) scan performed? (at last evaluation prior to the start of the preparative regimen / infusion) | no,yes | Was a PET (or PET/CT) scan performed? (at last evaluation prior to the start of the preparative regimen / infusion) | no,yes | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Was the PET (or PET/CT) scan positive for lymphoma involvement at any disease site? | no,yes | Was the PET (or PET/CT) scan positive for lymphoma involvement at any disease site? | no,yes | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Date of PET scan | Known,Unknown | Date of PET scan | Known,Unknown | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Date of PET (or PET/CT) scan: | YYYY/MM/DD | Date of PET (or PET/CT) scan: | YYYY/MM/DD | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Deauville (five-point) score of the PET (or PET/CT) scan | Known,Unknown | Deauville (five-point) score of the PET (or PET/CT) scan | Known,Unknown | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | 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 |
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 |
||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | What was the disease status? | CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to transplant,CR2 - 2nd complete remission,CR3+ - 3rd or subsequent complete remission,PIF res - Primary induction failure – resistant: NEVER in COMPLETE remission but with stable or progressive disease on treatment.,PIF sen / PR1 - Primary induction failure – sensitive: NEVER in COMPLETE remission but with partial remission on treatment.,PIF unk - Primary induction failure – sensitivity unknown,REL1 res - 1st relapse – resistant: stable or progressive disease with treatment,REL1 sen - 1st relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2),REL1 unk - 1st relapse – sensitivity unknown,REL1 unt - 1st relapse – untreated; includes either bone marrow or extramedullary relapse,REL2 res - 2nd relapse – resistant: stable or progressive disease with treatment,REL2 sen - 2nd relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+),REL2 unk - 2nd relapse – sensitivity unknown,REL2 unt - 2nd relapse – untreated: includes either bone marrow or extramedullary relapse,REL3+ res - 3rd or subsequent relapse – resistant: stable or progressive disease with treatment,REL3+ sen - 3rd or subsequent relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+),REL3+ unk - 3rd relapse or greater – sensitivity unknown,REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse,Disease untreated | What was the disease status? | CR1 - 1st complete remission: no bone marrow or extramedullary relapse prior to transplant,CR2 - 2nd complete remission,CR3+ - 3rd or subsequent complete remission,PIF res - Primary induction failure – resistant: NEVER in COMPLETE remission but with stable or progressive disease on treatment.,PIF sen / PR1 - Primary induction failure – sensitive: NEVER in COMPLETE remission but with partial remission on treatment.,PIF unk - Primary induction failure – sensitivity unknown,REL1 res - 1st relapse – resistant: stable or progressive disease with treatment,REL1 sen - 1st relapse – sensitive: partial remission (if complete remission was achieved, classify as CR2),REL1 unk - 1st relapse – sensitivity unknown,REL1 unt - 1st relapse – untreated; includes either bone marrow or extramedullary relapse,REL2 res - 2nd relapse – resistant: stable or progressive disease with treatment,REL2 sen - 2nd relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+),REL2 unk - 2nd relapse – sensitivity unknown,REL2 unt - 2nd relapse – untreated: includes either bone marrow or extramedullary relapse,REL3+ res - 3rd or subsequent relapse – resistant: stable or progressive disease with treatment,REL3+ sen - 3rd or subsequent relapse – sensitive: partial remission (if complete remission achieved, classify as CR3+),REL3+ unk - 3rd relapse or greater – sensitivity unknown,REL3+ unt - 3rd or subsequent relapse – untreated; includes either bone marrow or extramedullary relapse,Disease untreated | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Total number of lines of therapy received (between diagnosis and HCT / infusion) | 1 line,2 lines,3+ lines | Total number of lines of therapy received (between diagnosis and HCT / infusion) | 1 line,2 lines,3+ lines | ||
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify the multiple myeloma/plasma cell disorder (PCD) classification | Amyloidosis,Monoclonal gammopathy of renal significance (MGRS),Multiple myeloma,Multiple myeloma-light chain only,Multiple myeloma-non-secretory,Osteosclerotic myeloma / POEMS syndrome,Other plasma cell disorder (PCD),Plasma cell leukemia (PCL),Smoldering myeloma,Solitary plasmacytoma | Specify the multiple myeloma/plasma cell disorder (PCD) classification | Amyloidosis,Monoclonal gammopathy of renal significance (MGRS),Multiple myeloma,Multiple myeloma-light chain only,Multiple myeloma-non-secretory,Osteosclerotic myeloma / POEMS syndrome,Other plasma cell disorder (PCD),Plasma cell leukemia (PCL),Smoldering myeloma,Solitary plasmacytoma | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify other plasma cell disorder: | open text | Specify other plasma cell disorder: | open text | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify heavy and/or light chain type (check all that apply) | IgA (heavy chain only),IgA kappa,IgA lambda,IgD (heavy chain only),IgD kappa,IgD lambda,IgE (heavy chain only),IgE kappa,IgE lambda,IgG (heavy chain only),IgG kappa,IgG lambda,IgM (heavy chain only),IgM kappa,IgM lambda,Kappa (light chain only),Lambda (light chain only) | Specify heavy and/or light chain type (check all that apply) | IgA (heavy chain only),IgA kappa,IgA lambda,IgD (heavy chain only),IgD kappa,IgD lambda,IgE (heavy chain only),IgE kappa,IgE lambda,IgG (heavy chain only),IgG kappa,IgG lambda,IgM (heavy chain only),IgM kappa,IgM lambda,Kappa (light chain only),Lambda (light chain only) | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify Amyloidosis classification | AH amyloidosis,AHL amyloidosis,AL amyloidosis | Specify Amyloidosis classification | AH amyloidosis,AHL amyloidosis,AL amyloidosis | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Select monoclonal gammopathy of renal significance (MGRS) classification | C3 glomerulopathy with monoclonal gammopathy,Crystal-storing histiocytosis,Immunotactoid glomerulopathy (ITGN)/ Glomerulonephritis with organized monoclonal microtubular immunoglobulin deposits (GOMMID),Light chain fanconi syndrome,Monoclonal immunoglobulin deposition disease (MIDD),Non-amyloid fibrillary glomerulonephritis,Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits (PGNMID),Proximal tubulopathy without crystals,Type 1 cryoglobulinemic glomerulonephritis,Unknown | Select monoclonal gammopathy of renal significance (MGRS) classification | C3 glomerulopathy with monoclonal gammopathy,Crystal-storing histiocytosis,Immunotactoid glomerulopathy (ITGN)/ Glomerulonephritis with organized monoclonal microtubular immunoglobulin deposits (GOMMID),Light chain fanconi syndrome,Monoclonal immunoglobulin deposition disease (MIDD),Non-amyloid fibrillary glomerulonephritis,Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits (PGNMID),Proximal tubulopathy without crystals,Type 1 cryoglobulinemic glomerulonephritis,Unknown | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Select monoclonal immunoglobulin deposition disease (MIDD) subtype | Heavy chain deposition disease (HCDD),Light chain deposition disease (LCDD),Light and heavy chain deposition disease (LHCDD) | Select monoclonal immunoglobulin deposition disease (MIDD) subtype | Heavy chain deposition disease (HCDD),Light chain deposition disease (LCDD),Light and heavy chain deposition disease (LHCDD) | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Was documentation submitted to the CIBMTR? (e.g. pathology report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. pathology report) | No,Yes | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Solitary plasmacytoma was | Bone derived,Extramedullary | Solitary plasmacytoma was | Bone derived,Extramedullary | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | 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) – ,Stage II (Fitting neither Stage I or Stage III) ,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) ,Unknown | 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) – ,Stage II (Fitting neither Stage I or Stage III) ,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) ,Unknown | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | 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) | 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) | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Did the recipient have a preceding or concurrent plasma cell disorder? | No,Yes | Did the recipient have a preceding or concurrent plasma cell disorder? | No,Yes | ||
| Disease Classification | Preceding or Concurrent Plasma Cell Disorder | yes | yes | Specify preceding / concurrent disorder | Amyloidosis,Monoclonal gammopathy of renal significance,Monoclonal gammopathy of unknown significance,Multiple myeloma,Multiple myeloma - light chain only,Multiple myeloma - non-secretory,Osteosclerotic myeloma / POEMS syndrome,Other disease,Plasma cell leukemia,Smoldering myeloma,Solitary plasmacytoma | Specify preceding / concurrent disorder | Amyloidosis,Monoclonal gammopathy of renal significance,Monoclonal gammopathy of unknown significance,Multiple myeloma,Multiple myeloma - light chain only,Multiple myeloma - non-secretory,Osteosclerotic myeloma / POEMS syndrome,Other disease,Plasma cell leukemia,Smoldering myeloma,Solitary plasmacytoma | ||
| Disease Classification | Preceding or Concurrent Plasma Cell Disorder | yes | yes | Specify other preceding/concurrent disorder: | open text | Specify other preceding/concurrent disorder: | open text | ||
| Disease Classification | Preceding or Concurrent Plasma Cell Disorder | yes | yes | Date of diagnosis of preceding / concurrent disorder: | YYYY/MM/DD | Date of diagnosis of preceding / concurrent disorder: | YYYY/MM/DD | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Serum beta2 - microglobulin | Known,Unknown | Serum beta2 - microglobulin | Known,Unknown | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Serum beta2-microglobulin: | : ___ ___ ___ ● ___ ___ ___ μg/dL : ___ ___ ___ ● ___ ___ ___ mg/L : ___ ___ ___ ● ___ ___ ___ nmol/L |
Serum beta2-microglobulin: | : ___ ___ ___ ● ___ ___ ___ μg/dL : ___ ___ ___ ● ___ ___ ___ mg/L : ___ ___ ___ ● ___ ___ ___ nmol/L |
||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Serum albumin | Known,Unknown | Serum albumin | Known,Unknown | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Serum albumin: | : ___ ___ ● ___ g/dL : ___ ___ ● ___ g/L |
Serum albumin: | : ___ ___ ● ___ g/dL : ___ ___ ● ___ g/L |
||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | I.S.S Stage | Known,Unknown | I.S.S Stage | Known,Unknown | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | I.S.S Stage | 1 (Serum β2-microglobulin < 3.5 mg/L, Serum albumin ≥ 3.5 g/dL), 2(Not fitting stage 1 or 3) ,3 (Serum β2-microglobulin ≥ 5.5 mg/L; Serum albumin —) | I.S.S Stage | 1 (Serum β2-microglobulin < 3.5 mg/L, Serum albumin ≥ 3.5 g/dL), 2(Not fitting stage 1 or 3) ,3 (Serum β2-microglobulin ≥ 5.5 mg/L; Serum albumin —) | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | R-I.S.S Stage | Known,Unknown | R-I.S.S Stage | Known,Unknown | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | R-I.S.S Stage | 1 (ISS stage I and no high-risk cytogenetic abnormalities by FISH [deletion 17p / 17p-, t(4;14), t(14;16)] and normal LDH levels),2(Not R-ISS stage I or III),3(ISS stage III and either high-risk cytogenetic abnormalities by FISH [deletion 17p / 17p-, t(4;14), t(14;16)] or high LDH levels) | R-I.S.S Stage | 1 (ISS stage I and no high-risk cytogenetic abnormalities by FISH [deletion 17p / 17p-, t(4;14), t(14;16)] and normal LDH levels),2(Not R-ISS stage I or III),3(ISS stage III and either high-risk cytogenetic abnormalities by FISH [deletion 17p / 17p-, t(4;14), t(14;16)] or high LDH levels) | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Plasma cells in blood by flow cytometry | Known,Unknown | Change/Clarification of Information Requested | Plasma cells in peripheral blood by flow cytometry | Known,Unknown | Capture data accurately |
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Plasma cells in blood by flow cytometry | ___ ___• ___ ___ % | Plasma cells in blood by flow cytometry | ___ ___• ___ ___ % | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Plasma cells in blood by morphologic assessment | Known,Unknown | Change/Clarification of Information Requested | Plasma cells in peripheral blood by morphologic assessment | Known,Unknown | Capture data accurately |
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Plasma cells in blood by morphologic assessment | ___ ___• ___ ___ % | Plasma cells in blood by morphologic assessment | ___ ___• ___ ___ % | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Plasma cells in blood by morphologic assessment | ___ ___ ___ ___ ___ • ___ ___ □ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ • ___ ___ □ x 106/L |
Plasma cells in blood by morphologic assessment | ___ ___ ___ ___ ___ • ___ ___ □ x 109/L (x 103/mm3) ___ ___ ___ ___ ___ • ___ ___ □ x 106/L |
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| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | LDH | Known,Unknown | LDH | Known,Unknown | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | LDH | ___ ___ ___ ___ ___ ● ___ ___ o U/L ___ ___ ___ ___ ___ ● ___ ___ o μkat/L |
LDH | ___ ___ ___ ___ ___ ● ___ ___ o U/L ___ ___ ___ ___ ___ ● ___ ___ o μkat/L |
||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Upper limit of normal for LDH: | ___ ___ ___ ___ ___ • ___ ___ | Upper limit of normal for LDH: | ___ ___ ___ ___ ___ • ___ ___ | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis) | no,Unknown,yes | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis) | no,Unknown,yes | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Were cytogenetics tested via FISH? | No,Yes | Were cytogenetics tested via FISH? | No,Yes | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Results of tests | Abnormalities identified,No abnormalities | Results of tests | Abnormalities identified,No abnormalities | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify abnormalities (check all that apply) | Any abnormality at 1p,Any abnormality at 1q,del(13q) / 13q-,del(17p) / 17p-,Hyperdiploid (> 50),Hypodiploid (< 46),-13,-17,MYC rearrangement,Other abnormality,t(11;14),t(14;16),t(14;20),t(4;14),t(6;14),+11,+15,+19,+3,+5,+7,+9 | Specify abnormalities (check all that apply) | Any abnormality at 1p,Any abnormality at 1q,del(13q) / 13q-,del(17p) / 17p-,Hyperdiploid (> 50),Hypodiploid (< 46),-13,-17,MYC rearrangement,Other abnormality,t(11;14),t(14;16),t(14;20),t(4;14),t(6;14),+11,+15,+19,+3,+5,+7,+9 | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Was documentation submitted to the CIBMTR? (e.g. FISH report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. FISH report) | No,Yes | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Were cytogenetics tested via karyotyping? | No,Yes | Were cytogenetics tested via karyotyping? | No,Yes | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | Results of tests | Abnormalities identified,No abnormalities,No evaluable metaphases | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | International System for Human Cytogenetic Nomenclature (ISCN) compatible string: | open text | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify abnormalities (check all that apply) | Any abnormality at 1p,Any abnormality at 1q,del(13q) / 13q-,del(17p) / 17p-,Hyperdiploid (> 50),Hypodiploid (< 46),-13,-17,MYC rearrangement,Other abnormality,t(11;14),t(14;16),t(14;20),t(4;14),t(6;14),+11,+15,+19,+3,+5,+7,+9 | Specify abnormalities (check all that apply) | Any abnormality at 1p,Any abnormality at 1q,del(13q) / 13q-,del(17p) / 17p-,Hyperdiploid (> 50),Hypodiploid (< 46),-13,-17,MYC rearrangement,Other abnormality,t(11;14),t(14;16),t(14;20),t(4;14),t(6;14),+11,+15,+19,+3,+5,+7,+9 | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify other abnormality: | open text | Specify other abnormality: | open text | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Was documentation submitted to the CIBMTR? (e.g. karyotyping report) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. karyotyping report) | No,Yes | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | What is the hematologic disease status? | Complete remission (CR),Progressive disease (PD),Partial remission (PR),Relapse from CR (Rel) (untreated),Stringent complete remission (sCR),Stable disease (SD),Unknown,Very good partial remission (VGPR) | What is the hematologic disease status? | Complete remission (CR),Progressive disease (PD),Partial remission (PR),Relapse from CR (Rel) (untreated),Stringent complete remission (sCR),Stable disease (SD),Unknown,Very good partial remission (VGPR) | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Specify amyloidosis hematologic response (for Amyloid patients only) | Complete response (CR),No response (NR) / stable disease (SD),Progressive disease (PD),Partial response (PR),Relapse from CR (Rel) (untreated),Unknown,Very good partial response (VGPR) | Specify amyloidosis hematologic response (for Amyloid patients only) | Complete response (CR),No response (NR) / stable disease (SD),Progressive disease (PD),Partial response (PR),Relapse from CR (Rel) (untreated),Unknown,Very good partial response (VGPR) | ||
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Solid Tumors | yes | no | Specify the solid tumor classification | Breast cancer,Bone sarcoma (excluding Ewing family tumors),Cervical,Central nervous system tumor, including CNS PNET,Colorectal,Ovarian (epithelial),Ewing family tumors, extraosseous (including PNET),Ewing family tumors of bone (including PNET),External genitalia,Fibrosarcoma,Gastric,Germ cell tumor, extragonadal,Hepatobiliary,Head / neck,Hemangiosarcoma,Lung, not otherwise specified,Leiomyosarcoma,Lymphangio sarcoma,Liposarcoma,Medulloblastoma,Mediastinal neoplasm,Melanoma,Neuroblastoma,Neurogenic sarcoma,Lung, non-small cell,Other solid tumor,Prostate,Renal cell,Retinoblastoma,Rhabdomyosarcoma,Lung, small cell,Synovial sarcoma,Solid tumor, not otherwise specified,Pancreatic,Soft tissue sarcoma (excluding Ewing family tumors),Testicular,Thymoma,Uterine,Vaginal,Wilm Tumor | Specify the solid tumor classification | Breast cancer,Bone sarcoma (excluding Ewing family tumors),Cervical,Central nervous system tumor, including CNS PNET,Colorectal,Ovarian (epithelial),Ewing family tumors, extraosseous (including PNET),Ewing family tumors of bone (including PNET),External genitalia,Fibrosarcoma,Gastric,Germ cell tumor, extragonadal,Hepatobiliary,Head / neck,Hemangiosarcoma,Lung, not otherwise specified,Leiomyosarcoma,Lymphangio sarcoma,Liposarcoma,Medulloblastoma,Mediastinal neoplasm,Melanoma,Neuroblastoma,Neurogenic sarcoma,Lung, non-small cell,Other solid tumor,Prostate,Renal cell,Retinoblastoma,Rhabdomyosarcoma,Lung, small cell,Synovial sarcoma,Solid tumor, not otherwise specified,Pancreatic,Soft tissue sarcoma (excluding Ewing family tumors),Testicular,Thymoma,Uterine,Vaginal,Wilm Tumor | ||
| Disease Classification | Solid Tumors | yes | no | Specify other solid tumor: | open text | Specify other solid tumor: | open text | ||
| Disease Classification | Aplastic Anemia | yes | no | Specify the aplastic anemia classification – If the recipient developed MDS or AML, indicate MDS or AML as the primary disease. | Acquired amegakaryocytosis (not congenital),Acquired pure red cell aplasia (not congenital),Acquired AA, not otherwise specified,Other acquired cytopenic syndrome,Acquried AA secondary to chemotherapy,Acquired AA, secondary to hepatitis,Acquired AA secondary to immunotherapy or immune effector cell therapy,Acquired AA, secondary to toxin / other drug | Specify the aplastic anemia classification – If the recipient developed MDS or AML, indicate MDS or AML as the primary disease. | Acquired amegakaryocytosis (not congenital),Acquired pure red cell aplasia (not congenital),Acquired AA, not otherwise specified,Other acquired cytopenic syndrome,Acquried AA secondary to chemotherapy,Acquired AA, secondary to hepatitis,Acquired AA secondary to immunotherapy or immune effector cell therapy,Acquired AA, secondary to toxin / other drug | ||
| Disease Classification | Aplastic Anemia | yes | no | Specify severity | Not severe,Severe / very severe | Specify severity | Not severe,Severe / very severe | ||
| Disease Classification | Aplastic Anemia | yes | no | Specify other acquired cytopenic syndrome: | open text | Specify other acquired cytopenic syndrome: | open text | ||
| Disease Classification | Inherited Bone Marrow Failure Syndromes | yes | no | Specify the inherited bone marrow failure syndrome classification | Dyskeratosis congenita,Fanconi anemia,Severe congenital neutropenia,Diamond-Blackfan anemia,Shwachman-Diamond | Change/Clarification of Response Options | Specify the inherited bone marrow failure syndrome classification | Dyskeratosis congenita,Fanconi anemia,Severe congenital neutropenia,Diamond-Blackfan anemia,Shwachman-Diamond, Other inherited bone failure syndromes | Be consistent with current clinical landscape, improve transplant outcome data |
| Disease Classification | Inherited Bone Marrow Failure Syndromes | yes | no | Did the recipient receive gene therapy to treat the inherited bone marrow failure syndrome? | No,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Disease Classification | Hemoglobinopathies | yes | no | Specify the hemoglobinopathy classification | Other hemoglobinopathy,Sickle cell disease,Transfusion dependent thalassemia | Specify the hemoglobinopathy classification | Other hemoglobinopathy,Sickle cell disease,Transfusion dependent thalassemia | ||
| Disease Classification | Hemoglobinopathies | yes | no | Specify transfusion dependent thalassemia | Transfusion dependent beta thalassemia,Other transfusion dependent thalassemia | Specify transfusion dependent thalassemia | Transfusion dependent beta thalassemia,Other transfusion dependent thalassemia | ||
| Disease Classification | Hemoglobinopathies | yes | no | Specify other hemoglobinopathy: | open text | Specify other hemoglobinopathy: | open text | ||
| Disease Classification | Hemoglobinopathies | yes | no | Did the recipient receive gene therapy to treat the hemoglobinopathy? | No,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Disease Classification | Hemoglobinopathies | yes | no | Was tricuspid regurgitant jet velocity (TRJV) measured by echocardiography? | No,Unknown,Yes | Was tricuspid regurgitant jet velocity (TRJV) measured by echocardiography? | No,Unknown,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | TRJV measurement | Known,Unknown | TRJV measurement | Known,Unknown | ||
| Disease Classification | Hemoglobinopathies | yes | no | TRJV measurement: | __ __● ___ m/sec | TRJV measurement: | __ __● ___ m/sec | ||
| Disease Classification | Hemoglobinopathies | yes | no | Was liver iron content (LIC) tested within 6 months prior to infusion? | No,Yes | Was liver iron content (LIC) tested within 6 months prior to infusion? | No,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Liver iron content: | ___ ___ ___ ● ___mg Fe/g liver dry weight ___ ___ ___ ● ___g Fe/kg liver dry weight ___ ___ ___ ● ___µmol Fe / g liver dry weight |
Liver iron content: | ___ ___ ___ ● ___mg Fe/g liver dry weight ___ ___ ___ ● ___g Fe/kg liver dry weight ___ ___ ___ ● ___µmol Fe / g liver dry weight |
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| Disease Classification | Hemoglobinopathies | yes | no | Method used to estimate LIC? | FerriScan,Liver Biopsy,Other,SQUID MRI,T2 MRI | Method used to estimate LIC? | FerriScan,Liver Biopsy,Other,SQUID MRI,T2 MRI | ||
| Disease Classification | Hemoglobinopathies | yes | no | Is the recipient red blood cell transfusion dependent? (requiring transfusion to maintain HGB 9-10 g/dL) | No,Yes | Is the recipient red blood cell transfusion dependent? (requiring transfusion to maintain HGB 9-10 g/dL) | No,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Year of first transfusion: (since diagnosis): | YYYY | Year of first transfusion: (since diagnosis): | YYYY | ||
| Disease Classification | Hemoglobinopathies | yes | no | Was iron chelation therapy given at any time since diagnosis? | No,Unknown,Yes | Was iron chelation therapy given at any time since diagnosis? | No,Unknown,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Did iron chelation therapy meet the following criteria: initiated within 18 months of the first transfusion and administered for at least 5 days / week (either oral or parenteral iron chelation medication)? | No, iron chelation therapy given, but not meeting criteria,Iron chelation therapy given, but details of administration unknown,Yes, iron chelation therapy given as specified | Did iron chelation therapy meet the following criteria: initiated within 18 months of the first transfusion and administered for at least 5 days / week (either oral or parenteral iron chelation medication)? | No, iron chelation therapy given, but not meeting criteria,Iron chelation therapy given, but details of administration unknown,Yes, iron chelation therapy given as specified | ||
| Disease Classification | Hemoglobinopathies | yes | no | Specify reason criteria not met | Non-adherence,Other,Toxicity due to iron chelation therapy | Specify reason criteria not met | Non-adherence,Other,Toxicity due to iron chelation therapy | ||
| Disease Classification | Hemoglobinopathies | yes | no | Specify other reason criteria not met: | open text | Specify other reason criteria not met: | open text | ||
| Disease Classification | Hemoglobinopathies | yes | no | Year iron chelation therapy started | Known,Unknown | Year iron chelation therapy started | Known,Unknown | ||
| Disease Classification | Hemoglobinopathies | yes | no | Year started: | YYYY | Year started: | YYYY | ||
| Disease Classification | Hemoglobinopathies | yes | no | Did the recipient have hepatomegaly? (≥ 2 cm below costal margin) | no,Unknown,yes | Did the recipient have hepatomegaly? (≥ 2 cm below costal margin) | no,Unknown,yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Liver size as measured below the costal margin at most recent evaluation: | __ __ cm | Liver size as measured below the costal margin at most recent evaluation: | __ __ cm | ||
| Disease Classification | Hemoglobinopathies | yes | no | Was a liver biopsy performed at any time since diagnosis? | no,yes | Was a liver biopsy performed at any time since diagnosis? | no,yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Date functional status assessed | Known,Unknown | Date functional status assessed | Known,Unknown | ||
| Disease Classification | Hemoglobinopathies | yes | no | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | ||
| Disease Classification | Hemoglobinopathies | yes | no | Date estimated | checked | Date estimated | checked | ||
| Disease Classification | Hemoglobinopathies | yes | no | Was there evidence of liver cirrhosis? | No,Unknown,Yes | Was there evidence of liver cirrhosis? | No,Unknown,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Was there evidence of liver fibrosis? | No,Unknown,Yes | Was there evidence of liver fibrosis? | No,Unknown,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Type of fibrosis | Bridging,Other,Periportal,Unknown | Type of fibrosis | Bridging,Other,Periportal,Unknown | ||
| Disease Classification | Hemoglobinopathies | yes | no | Was there evidence of chronic hepatitis? | No,Unknown,Yes | Was there evidence of chronic hepatitis? | No,Unknown,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Was documentation submitted to the CIBMTR? (e.g. liver biopsy) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. liver biopsy) | No,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Is there evidence of abnormal cardiac iron deposition based on MRI of the heart at time of infusion? | No,Yes | Is there evidence of abnormal cardiac iron deposition based on MRI of the heart at time of infusion? | No,Yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Did the recipient have a splenectomy? | no,Unknown,yes | Did the recipient have a splenectomy? | no,Unknown,yes | ||
| Disease Classification | Hemoglobinopathies | yes | no | Serum iron | Known,Unknown | Serum iron | Known,Unknown | ||
| Disease Classification | Hemoglobinopathies | yes | no | Serum iron: | : ___ ___ ___● ___ ___ µg / dL : ___ ___ ___● ___ ___µmol / L |
Serum iron: | : ___ ___ ___● ___ ___ µg / dL : ___ ___ ___● ___ ___µmol / L |
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| Disease Classification | Hemoglobinopathies | yes | no | Total iron binding capacity (TIBC) | Known,Unknown | Total iron binding capacity (TIBC) | Known,Unknown | ||
| Disease Classification | Hemoglobinopathies | yes | no | TIBC: | : ___ ___ ___● ___ ___ µg / dL : ___ ___ ___● ___ ___µmol / L |
TIBC: | : ___ ___ ___● ___ ___ µg / dL : ___ ___ ___● ___ ___µmol / L |
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| Disease Classification | Hemoglobinopathies | yes | no | Total serum bilirubin | Known,Unknown | Total serum bilirubin | Known,Unknown | ||
| Disease Classification | Hemoglobinopathies | yes | no | Total serum bilirubin: | : ___ ___ ___● ___ ___ mg/dL : ___ ___ ___● ___ ___µmol / L |
Total serum bilirubin: | : ___ ___ ___● ___ ___ mg/dL : ___ ___ ___● ___ ___µmol / L |
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| Disease Classification | Hemoglobinopathies | yes | no | Upper limit of normal for total serum bilirubin: | __ __ __ ● __ | Upper limit of normal for total serum bilirubin: | __ __ __ ● __ | ||
| Disease Classification | Disorders of the Immune System | yes | no | Specify disorder of immune system classification | Ataxia telangiectasia,Bare lymphocyte syndrome,Cartilage hair hypoplasia,CD40 ligand deficiency,Chronic granulomatous disease,DiGeorge anomaly,Griscelli syndrome type 2,HIV infection,Hermansky-Pudlak syndrome type 2,Leukocyte adhesion deficiencies, including GP180, CD-18, LFA and WBC adhesion deficiencies,Neutrophil actin deficiency,Chediak-Higashi syndrome,Other immunodeficiencies,Omenn syndrome,Other pigmentary dilution disorder,Other SCID,Reticular dysgenesis,Adenosine deaminase (ADA) deficiency / severe combined immunodeficiency (SCID),SCID, not otherwise specified,Absence of T and B cells SCID,Absence of T, normal B cell SCID,Immune deficiency, not otherwise specified,Common variable immunodeficiency,Wiskott-Aldrich syndrome,X-linked lymphoproliferative syndrome | Specify disorder of immune system classification | Ataxia telangiectasia,Bare lymphocyte syndrome,Cartilage hair hypoplasia,CD40 ligand deficiency,Chronic granulomatous disease,DiGeorge anomaly,Griscelli syndrome type 2,HIV infection,Hermansky-Pudlak syndrome type 2,Leukocyte adhesion deficiencies, including GP180, CD-18, LFA and WBC adhesion deficiencies,Neutrophil actin deficiency,Chediak-Higashi syndrome,Other immunodeficiencies,Omenn syndrome,Other pigmentary dilution disorder,Other SCID,Reticular dysgenesis,Adenosine deaminase (ADA) deficiency / severe combined immunodeficiency (SCID),SCID, not otherwise specified,Absence of T and B cells SCID,Absence of T, normal B cell SCID,Immune deficiency, not otherwise specified,Common variable immunodeficiency,Wiskott-Aldrich syndrome,X-linked lymphoproliferative syndrome | ||
| Disease Classification | Disorders of the Immune System | yes | no | Specify other SCID: | open text | Specify other SCID: | open text | ||
| Disease Classification | Disorders of the Immune System | yes | no | Specify other immunodeficiency: | open text | Specify other immunodeficiency: | open text | ||
| Disease Classification | Disorders of the Immune System | yes | no | Specify other pigmentary dilution disorder: | open text | Specify other pigmentary dilution disorder: | open text | ||
| Disease Classification | Disorders of the Immune System | yes | no | Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT? | No,Yes | Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT? | No,Yes | ||
| Disease Classification | Disorders of the Immune System | yes | no | Specify viral pathogen (check all that apply) | Adenovirus,BK Virus,Chikaugunya Virus,Cytomegalovirus (CMV),Coronavirus,Dengue Virus,Epstein-Barr Virus (EBV),Enterovirus D68 (EV-D68),Enterovirus (ECHO, Coxsackie),Enterovirus, NOS,Enterovirus (polio),Hepatitis A Virus,Hepatitis B Virus,Hepatitis C Virus,Hepatitis E,Human herpesvirus 6 (HHV-6),Human Immunodeficiency Virus 1 or 2,Human metapneumovirus,Human Papillomavirus (HPV),Herpes Simplex Virus (HSV),Human T-lymphotropic Virus 1 or 2,Influenza A Virus,Influenza B Virus,Influenza, NOS,JC Virus (Progressive Multifocal Leukoencephalopathy (PML)),Measles Virus (Rubeola),Mumps Virus,Norovirus,Human Parainfluenza Virus (all species),Rhinovirus (all species),Rotavirus (all species),Respiratory Syncytial Virus (RSV),Rubella Virus,Varicella Virus,West Nile Virus (WNV) | Specify viral pathogen (check all that apply) | Adenovirus,BK Virus,Chikaugunya Virus,Cytomegalovirus (CMV),Coronavirus,Dengue Virus,Epstein-Barr Virus (EBV),Enterovirus D68 (EV-D68),Enterovirus (ECHO, Coxsackie),Enterovirus, NOS,Enterovirus (polio),Hepatitis A Virus,Hepatitis B Virus,Hepatitis C Virus,Hepatitis E,Human herpesvirus 6 (HHV-6),Human Immunodeficiency Virus 1 or 2,Human metapneumovirus,Human Papillomavirus (HPV),Herpes Simplex Virus (HSV),Human T-lymphotropic Virus 1 or 2,Influenza A Virus,Influenza B Virus,Influenza, NOS,JC Virus (Progressive Multifocal Leukoencephalopathy (PML)),Measles Virus (Rubeola),Mumps Virus,Norovirus,Human Parainfluenza Virus (all species),Rhinovirus (all species),Rotavirus (all species),Respiratory Syncytial Virus (RSV),Rubella Virus,Varicella Virus,West Nile Virus (WNV) | ||
| Disease Classification | Disorders of the Immune System | yes | no | Has the recipient ever been infected with PCP / PJP? | No,Yes | Has the recipient ever been infected with PCP / PJP? | No,Yes | ||
| Disease Classification | Disorders of the Immune System | yes | no | Does the recipient have GVHD due to maternal cell engraftment pre-HCT? (SCID only) | No,Yes | Does the recipient have GVHD due to maternal cell engraftment pre-HCT? (SCID only) | No,Yes | ||
| Disease Classification | Inherited Abnormalities of Platelets | yes | no | Specify inherited abnormalities of platelets classification | Congenital amegakaryocytosis / congenital thrombocytopenia (501),Glanzmann thrombasthenia (502),Other inherited platelet abnormality (509) | Specify inherited abnormalities of platelets classification | Congenital amegakaryocytosis / congenital thrombocytopenia (501),Glanzmann thrombasthenia (502),Other inherited platelet abnormality (509) | ||
| Disease Classification | Inherited Abnormalities of Platelets | yes | no | Specify other inherited platelet abnormality: | open text | Specify other inherited platelet abnormality: | open text | ||
| Disease Classification | Inherited Disorders of Metabolism | yes | no | Specify inherited disorders of metabolism classification | Adrenoleukodystrophy (ALD) (543),Aspartyl glucosaminidase (561),ß-glucuronidase deficiency (VII) (537),Fucosidosis (562),Gaucher disease (541),Glucose storage disease (548),Hunter syndrome (II) (533),Hurler syndrome (IH) (531),I-cell disease (546),Krabbe disease (globoid leukodystrophy) (544),Lesch-Nyhan (HGPRT deficiency) (522),Mannosidosis (563),Maroteaux-Lamy (VI) (536),Metachromatic leukodystrophy (MLD) (542),Mucolipidoses, not otherwise specified (540),Morquio (IV) (535),Mucopolysaccharidosis (V) (538),Mucopolysaccharidosis, not otherwise specified (530),Niemann-Pick disease (545),Neuronal ceroid lipofuscinosis (Batten disease) (523),Other inherited metabolic disorder (529),Osteopetrosis (malignant infantile osteopetrosis) (521),Polysaccharide hydrolase abnormality, not otherwise specified (560),Sanfilippo (III) (534),Scheie syndrome (IS) (532),Inherited metabolic disorder, not otherwise specified (520),Wolman disease (547) | Change/Clarification of Response Options | Specify inherited disorders of metabolism classification | Hereditary diffuse leukoencephalopathy with spheroids, Adrenoleukodystrophy (ALD) (543),Aspartyl glucosaminidase (561),ß-glucuronidase deficiency (VII) (537),Fucosidosis (562),Gaucher disease (541),Glucose storage disease (548),Hunter syndrome (II) (533),Hurler syndrome (IH) (531),I-cell disease (546),Krabbe disease (globoid leukodystrophy) (544),Lesch-Nyhan (HGPRT deficiency) (522),Mannosidosis (563),Maroteaux-Lamy (VI) (536),Metachromatic leukodystrophy (MLD) (542),Mucolipidoses, not otherwise specified (540),Morquio (IV) (535),Mucopolysaccharidosis (V) (538),Mucopolysaccharidosis, not otherwise specified (530),Niemann-Pick disease (545),Neuronal ceroid lipofuscinosis (Batten disease) (523),Other inherited metabolic disorder (529),Osteopetrosis (malignant infantile osteopetrosis) (521),Polysaccharide hydrolase abnormality, not otherwise specified (560),Sanfilippo (III) (534),Scheie syndrome (IS) (532),Inherited metabolic disorder, not otherwise specified (520),Wolman disease (547) | Be consistent with current clinical landscape, improve transplant outcome data |
| Disease Classification | Inherited Disorders of Metabolism | yes | no | Specify other inherited metabolic disorder: | open text | Specify other inherited metabolic disorder: | open text | ||
| Disease Classification | Inherited Disorders of Metabolism | yes | no | Loes composite score | __ __ Adrenoleukodystrophy (ALD) only | Loes composite score | __ __ Adrenoleukodystrophy (ALD) only | ||
| Disease Classification | Histiocytic Disorders | yes | no | Specify histiocytic disorder classification | Histiocytic disorder, not otherwise specified (570),Langerhans cell histiocytosis (histiocytosis-X) (572),Hemophagocytic lymphohistiocytosis (HLH) (571),Hemophagocytosis (reactive or viral associated) (573),Malignant histiocytosis (574),Other histiocytic disorder (579) | Specify histiocytic disorder classification | Histiocytic disorder, not otherwise specified (570),Langerhans cell histiocytosis (histiocytosis-X) (572),Hemophagocytic lymphohistiocytosis (HLH) (571),Hemophagocytosis (reactive or viral associated) (573),Malignant histiocytosis (574),Other histiocytic disorder (579) | ||
| Disease Classification | Histiocytic Disorders | yes | no | Specify other histiocytic disorder: | open text | Specify other histiocytic disorder: | open text | ||
| Disease Classification | Histiocytic Disorders | yes | no | Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT? Hemophagocytic lymphohistiocytosis (HLH) only | No,Yes | Did the recipient have an active or recent infection with a viral pathogen within 60 days of HCT? Hemophagocytic lymphohistiocytosis (HLH) only | No,Yes | ||
| Disease Classification | Histiocytic Disorders | yes | no | Specify viral pathogen (check all that apply) | Adenovirus,BK Virus,Chikaugunya Virus,Cytomegalovirus (CMV),Coronavirus,Dengue Virus,Epstein-Barr Virus (EBV),Enterovirus D68 (EV-D68),Enterovirus (ECHO, Coxsackie),Enterovirus, NOS,Enterovirus (polio),Hepatitis A Virus,Hepatitis B Virus,Hepatitis C Virus,Hepatitis E,Human herpesvirus 6 (HHV-6),Human Immunodeficiency Virus 1 or 2,Human metapneumovirus,Human Papillomavirus (HPV),Herpes Simplex Virus (HSV),Human T-lymphotropic Virus 1 or 2,Influenza A Virus,Influenza B Virus,Influenza, NOS,JC Virus (Progressive Multifocal Leukoencephalopathy (PML)),Measles Virus (Rubeola),Mumps Virus,Norovirus,Human Parainfluenza Virus (all species),Rhinovirus (all species),Rotavirus (all species),Respiratory Syncytial Virus (RSV),Rubella Virus,Varicella Virus,West Nile Virus (WNV) | Specify viral pathogen (check all that apply) | Adenovirus,BK Virus,Chikaugunya Virus,Cytomegalovirus (CMV),Coronavirus,Dengue Virus,Epstein-Barr Virus (EBV),Enterovirus D68 (EV-D68),Enterovirus (ECHO, Coxsackie),Enterovirus, NOS,Enterovirus (polio),Hepatitis A Virus,Hepatitis B Virus,Hepatitis C Virus,Hepatitis E,Human herpesvirus 6 (HHV-6),Human Immunodeficiency Virus 1 or 2,Human metapneumovirus,Human Papillomavirus (HPV),Herpes Simplex Virus (HSV),Human T-lymphotropic Virus 1 or 2,Influenza A Virus,Influenza B Virus,Influenza, NOS,JC Virus (Progressive Multifocal Leukoencephalopathy (PML)),Measles Virus (Rubeola),Mumps Virus,Norovirus,Human Parainfluenza Virus (all species),Rhinovirus (all species),Rotavirus (all species),Respiratory Syncytial Virus (RSV),Rubella Virus,Varicella Virus,West Nile Virus (WNV) | ||
| Disease Classification | Histiocytic Disorders | yes | no | Has the recipient ever been infected with PCP / PJP? | No,Yes | Has the recipient ever been infected with PCP / PJP? | No,Yes | ||
| Disease Classification | Autoimmune Diseases | yes | no | Specify autoimmune disease classification | Antiphospholipid syndrome,Behcet syndrome,Churg-Strauss,Classical polyarteritis nodosa,Crohn's disease,Diabetes mellitus type I,Evan syndrome,Giant cell arteritis,Hemolytic anemia,Idiopathic thrombocytopenic purpura (ITP),Juvenile idiopathic arthritis (JIA): oligoarticular,Juvenile idiopathic arthritis (JIA): other,Juvenile idiopathic arthritis (JIA): polyarticular,Juvenile idiopathic arthritis (JIA): systemic (Stills disease),Microscopic polyarteritis nodosa,Multiple sclerosis,Myasthenia gravis,Other autoimmune disorder,Overlap necrotizing arteritis,Other arthritis,Other autoimmune bowel disorder,Other autoimmune cytopenia,Other autoimmune neurological disorder,Other connective tissue disease,Other vasculitis,Psoriatic arthritis / psoriasis,Polymyositis / dermatomyositis,Rheumatoid arthritis,Sjogren syndrome,Systemic lupus erythematosis (SLE),Systemic sclerosis,Takayasu,Ulcerative colitis,Wegener granulomatosis | Specify autoimmune disease classification | Antiphospholipid syndrome,Behcet syndrome,Churg-Strauss,Classical polyarteritis nodosa,Crohn's disease,Diabetes mellitus type I,Evan syndrome,Giant cell arteritis,Hemolytic anemia,Idiopathic thrombocytopenic purpura (ITP),Juvenile idiopathic arthritis (JIA): oligoarticular,Juvenile idiopathic arthritis (JIA): other,Juvenile idiopathic arthritis (JIA): polyarticular,Juvenile idiopathic arthritis (JIA): systemic (Stills disease),Microscopic polyarteritis nodosa,Multiple sclerosis,Myasthenia gravis,Other autoimmune disorder,Overlap necrotizing arteritis,Other arthritis,Other autoimmune bowel disorder,Other autoimmune cytopenia,Other autoimmune neurological disorder,Other connective tissue disease,Other vasculitis,Psoriatic arthritis / psoriasis,Polymyositis / dermatomyositis,Rheumatoid arthritis,Sjogren syndrome,Systemic lupus erythematosis (SLE),Systemic sclerosis,Takayasu,Ulcerative colitis,Wegener granulomatosis | ||
| Disease Classification | Autoimmune Diseases | yes | no | Specify other autoimmune cytopenia: | open text | Specify other autoimmune cytopenia: | open text | ||
| Disease Classification | Autoimmune Diseases | yes | no | Specify other autoimmune bowel disorder: | open text | Specify other autoimmune bowel disorder: | open text | ||
| Disease Classification | Autoimmune Diseases | yes | no | Specify other autoimmune disease: | open text | Specify other autoimmune disease: | open text | ||
| Disease Classification | Tolerance Induction Associated with Solid Organ Transplant | yes | no | Specify solid organ transplanted (check all that apply) | Kidney,Liver,Other organ,Pancreas | Specify solid organ transplanted (check all that apply) | Kidney,Liver,Other organ,Pancreas | ||
| Disease Classification | Tolerance Induction Associated with Solid Organ Transplant | yes | no | Specify other organ: | open text | Specify other organ: | open text | ||
| Disease Classification | Tolerance Induction Associated with Solid Organ Transplant | yes | no | Specify other disease: | open text | Specify other disease: | open text | ||
| Pre-Transplant Essential Data | yes | First Name (person completing form): | open text | First Name (person completing form): | open text | ||||
| Pre-Transplant Essential Data | yes | Last Name: | open text | Last Name: | open text | ||||
| Pre-Transplant Essential Data | yes | E-mail address: | open text | E-mail address: | open text | ||||
| Pre-Transplant Essential Data | yes | Date: | YYYY/MM/DD | Date: | YYYY/MM/DD |
Sheet 2: Transplant Procedure&Produc
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Information Collection Domain: Transplant Procedure and Product Information | ||||||||
| Information Collection Domain Sub-Type | Information Collection Domain Additional Sub Domain | Response required if Additional Sub Domain applies | Information Collection may be requested multiple times | Current Information Collection Data Element (if applicable) | Current Information Collection Data Element Response Option(s) | Information Collection update: | Proposed Information Collection Data Element (if applicable) | Proposed Information Collection Data Element Response Option(s) | Rationale for Information Collection Update |
| Infectious Disease Markers | yes | Sequence Number: | Auto Filled Field | Sequence Number: | Auto Filled Field | ||||
| Infectious Disease Markers | yes | Date Received: | Auto Filled Field | Date Received: | Auto Filled Field | ||||
| Infectious Disease Markers | yes | CIBMTR Center Number: | Auto Filled Field | CIBMTR Center Number: | Auto Filled Field | ||||
| Infectious Disease Markers | yes | CIBMTR Research ID: | Auto Filled Field | CIBMTR Research ID: | Auto Filled Field | ||||
| Infectious Disease Markers | Event date: | Auto Filled Field created with CRID | Event date: | Auto Filled Field created with CRID | |||||
| Infectious Disease Markers | no | no | HCT type (check all that apply) | Allogeneic, related,Allogeneic, unrelated | HCT type (check all that apply) | Allogeneic, related,Allogeneic, unrelated | |||
| Infectious Disease Markers | no | no | Product type (check all that apply) | Bone marrow,Other product,PBSC,Single cord blood unit | Product type (check all that apply) | Bone marrow,Other product,PBSC,Single cord blood unit | |||
| Infectious Disease Markers | no | no | Other product. Specify: | open text | Other product. Specify: | open text | |||
| Infectious Disease Markers | no | no | Registry donor ID: | open text | Registry donor ID: | open text | |||
| Infectious Disease Markers | no | no | Non-NMDP cord blood unit ID: | open text | Non-NMDP cord blood unit ID: | open text | |||
| Infectious Disease Markers | no | no | Global Registration Identifier for Donors (GRID) | open text | Global Registration Identifier for Donors (GRID) | open text | |||
| Infectious Disease Markers | no | no | ISBT DIN: | open text | ISBT DIN: | open text | |||
| Infectious Disease Markers | no | no | Registry or UCB Bank ID | (A) Austrian Bone Marrow Donors,(ACB) Austrian Cord Blood Registry,(ACCB) StemCyte, Inc,(AE) Emirates Bone Marrow Donor Registry,(AM) Armenian Bone Marrow Donor Registry Charitable Trust,(AOCB) University of Colorado Cord Blood Bank,(AR) Argentine CPH Donors Registry,(ARCB) BANCEL - Argentina Cord Blood Bank,(AUCB) Australian Cord Blood Registry,(AUS) Australian / New Zealand Bone Marrow Donor Registry,(B) Marrow Donor Program Belgium,(BCB) Belgium Cord Blood Registry,(BG) Bulgarian Bone Marrow Donor Registry,(BR) INCA/REDOMO,(BSCB) British Bone Marrow Registry - Cord Blood,(CB) Cord Blood Registry,(CH) Swiss BloodStem Cells - Adult Donors,(CHCB) Swiss Blood Stem Cells - Cord Blood,(CKCB) Celgene Cord Blood Bank,(CN) China Marrow Donor Program (CMDP),(CNCB) Shan Dong Cord Blood Bank,(CND) Canadian Blood Services Bone Marrow Donor Registry,(CS2) Czech National Marrow Donor Registry,(CSCR) Czech Stem Cells Registry,(CY) Cyprus Paraskevaidio Bone Marrow Donor Registry,(CY2) The Cyprus Bone Marrow Donor Registry,(D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors,(DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood,(DK) The Danish Bone Marrow Donor Registry,(DK2) Bone Marrow Donors Copenhagen (BMDC),(DUCB) German Branch of the European Cord Blood Bank,(E) REDMO,(ECB) Spanish Cord Blood Registry,(F) France Greffe de Moelle - Adult Donors,(FCB) France Greffe de Moelle - Cord Blood,(FI) Finnish Bone Marrow Donor Registry,(FICB) Finnish Cord Blood Registry,(GB) The Anthony Nolan Trust,(GB3) Welsh Bone Marrow Donor Registry,(GB4) British Bone Marrow Registry,(GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece,(GRCB) Michigan Community Blood Centers Cord Blood Bank,(H) Hungarian Bone Marrow Donor Registry,(HEM) Hema-Quebec,(HK) Hong Kong Bone Marrow Donor Registry,(HR) Croatian Bone Marrow Donor Registry,(I) Italian Bone Marrow Donor Registry,(I3CB) Sheba Medical Centre Cord Blood Registry,(ICB) Italian Cord Blood Bank Network,(IL) Hadassah BMDR,(IL2) Ezer Mizion Bone Marrow Donor Registry,(IL3) Sheba Medical Center Donor Registry,(ILCB) Isreal Cord Blood Bank,(IN) Asian Indian Donor Marrow Registry,(IN2) Dept. of Transfusion Medicine,(IRL) The Irish Unrelated Bone Marrow Panel,(JP) Japan Marrow Donor Program,(KR) Korea Marrow Donor Program,(LT) Lithuanian National Bone Marrow Donor Registry,(LVCB) Leuven Cord Blood Bank,(MACB) Victoria Angel Registry of Hope,(MX) Mexican Bone Marrow Donor Registry,(N) The Norwegian Bone Marrow Donor Registry,(NL) Europdonor Foundation- Adult Donors,(NLCB) Europdonor Foundation - Cord Blood,(NYCB) National Cord Blood Program, New York Blood Center,(OTH) Other Registry,(P) Portuguese Bone Marrow Donors Registry,(PL) National Polish Bone Marrow Registry,(PL2) Unrelated Bone Marrow Donor Registry -Adult Donors,(PL3) Against Leukemia Foundation Marrow Donor Registry,(PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry,(PL5) Polish Central Bone Marrow Donor Registry - Adult Donors,(PMCB) Elie Katz Umbilical Cord Blood Program,(R) Russian Bone Marrow Donor Registry,(R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells,(S) Tobias Registry of Swedish Bone Marrow Donors,(SG) Singapore Bone Marrow Donor Programme (BMDP),(SK) Slovak National Bone Marrow Donor Registry,(SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry,(SLCBB) St Louis Cord Blood Bank,(SLO) Slovenia Donor,(SM) San Marino Bone Marrow Donor Registry,(T1CB) TRAN - Cord Blood,(TACB) StemCyte, Inc. Taiwan,(TECB) Healthbanks Biotech, Co., Ltd,(TH) Thai Stem Cell Donor Registry (TSCDR),(TOCB) Tokyo Cord Blood Bank,(TPCB) BIONET / BabyBanks,(TRAN) TRAN - Adult Donors,(TRIS) Bone Marrow Bank of Istanbul Medical Faculty,(TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors,(TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood,(U1CB) National Marrow Donor Program - Cord Blood,(USA1) National Marrow Donor Program - Adult Donors,(USA2) America Bone Marrow Donor Registry,(UY) SINDOME,(VIAC) Viacord,(W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood,(WACB) Unrelated Bone Marrow Donor Registry - Cord Blood,(ZA) South African Bone Marrow Registry | Registry or UCB Bank ID | (A) Austrian Bone Marrow Donors,(ACB) Austrian Cord Blood Registry,(ACCB) StemCyte, Inc,(AE) Emirates Bone Marrow Donor Registry,(AM) Armenian Bone Marrow Donor Registry Charitable Trust,(AOCB) University of Colorado Cord Blood Bank,(AR) Argentine CPH Donors Registry,(ARCB) BANCEL - Argentina Cord Blood Bank,(AUCB) Australian Cord Blood Registry,(AUS) Australian / New Zealand Bone Marrow Donor Registry,(B) Marrow Donor Program Belgium,(BCB) Belgium Cord Blood Registry,(BG) Bulgarian Bone Marrow Donor Registry,(BR) INCA/REDOMO,(BSCB) British Bone Marrow Registry - Cord Blood,(CB) Cord Blood Registry,(CH) Swiss BloodStem Cells - Adult Donors,(CHCB) Swiss Blood Stem Cells - Cord Blood,(CKCB) Celgene Cord Blood Bank,(CN) China Marrow Donor Program (CMDP),(CNCB) Shan Dong Cord Blood Bank,(CND) Canadian Blood Services Bone Marrow Donor Registry,(CS2) Czech National Marrow Donor Registry,(CSCR) Czech Stem Cells Registry,(CY) Cyprus Paraskevaidio Bone Marrow Donor Registry,(CY2) The Cyprus Bone Marrow Donor Registry,(D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors,(DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood,(DK) The Danish Bone Marrow Donor Registry,(DK2) Bone Marrow Donors Copenhagen (BMDC),(DUCB) German Branch of the European Cord Blood Bank,(E) REDMO,(ECB) Spanish Cord Blood Registry,(F) France Greffe de Moelle - Adult Donors,(FCB) France Greffe de Moelle - Cord Blood,(FI) Finnish Bone Marrow Donor Registry,(FICB) Finnish Cord Blood Registry,(GB) The Anthony Nolan Trust,(GB3) Welsh Bone Marrow Donor Registry,(GB4) British Bone Marrow Registry,(GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece,(GRCB) Michigan Community Blood Centers Cord Blood Bank,(H) Hungarian Bone Marrow Donor Registry,(HEM) Hema-Quebec,(HK) Hong Kong Bone Marrow Donor Registry,(HR) Croatian Bone Marrow Donor Registry,(I) Italian Bone Marrow Donor Registry,(I3CB) Sheba Medical Centre Cord Blood Registry,(ICB) Italian Cord Blood Bank Network,(IL) Hadassah BMDR,(IL2) Ezer Mizion Bone Marrow Donor Registry,(IL3) Sheba Medical Center Donor Registry,(ILCB) Isreal Cord Blood Bank,(IN) Asian Indian Donor Marrow Registry,(IN2) Dept. of Transfusion Medicine,(IRL) The Irish Unrelated Bone Marrow Panel,(JP) Japan Marrow Donor Program,(KR) Korea Marrow Donor Program,(LT) Lithuanian National Bone Marrow Donor Registry,(LVCB) Leuven Cord Blood Bank,(MACB) Victoria Angel Registry of Hope,(MX) Mexican Bone Marrow Donor Registry,(N) The Norwegian Bone Marrow Donor Registry,(NL) Europdonor Foundation- Adult Donors,(NLCB) Europdonor Foundation - Cord Blood,(NYCB) National Cord Blood Program, New York Blood Center,(OTH) Other Registry,(P) Portuguese Bone Marrow Donors Registry,(PL) National Polish Bone Marrow Registry,(PL2) Unrelated Bone Marrow Donor Registry -Adult Donors,(PL3) Against Leukemia Foundation Marrow Donor Registry,(PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry,(PL5) Polish Central Bone Marrow Donor Registry - Adult Donors,(PMCB) Elie Katz Umbilical Cord Blood Program,(R) Russian Bone Marrow Donor Registry,(R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells,(S) Tobias Registry of Swedish Bone Marrow Donors,(SG) Singapore Bone Marrow Donor Programme (BMDP),(SK) Slovak National Bone Marrow Donor Registry,(SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry,(SLCBB) St Louis Cord Blood Bank,(SLO) Slovenia Donor,(SM) San Marino Bone Marrow Donor Registry,(T1CB) TRAN - Cord Blood,(TACB) StemCyte, Inc. Taiwan,(TECB) Healthbanks Biotech, Co., Ltd,(TH) Thai Stem Cell Donor Registry (TSCDR),(TOCB) Tokyo Cord Blood Bank,(TPCB) BIONET / BabyBanks,(TRAN) TRAN - Adult Donors,(TRIS) Bone Marrow Bank of Istanbul Medical Faculty,(TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors,(TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood,(U1CB) National Marrow Donor Program - Cord Blood,(USA1) National Marrow Donor Program - Adult Donors,(USA2) America Bone Marrow Donor Registry,(UY) SINDOME,(VIAC) Viacord,(W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood,(WACB) Unrelated Bone Marrow Donor Registry - Cord Blood,(ZA) South African Bone Marrow Registry | |||
| Infectious Disease Markers | no | no | Donor DOB: | YYYY/MM/DD | Donor DOB: | YYYY/MM/DD | |||
| Infectious Disease Markers | no | no | Donor age: | open text, check "Months" or check "Years" | Donor age: | open text, check "Months" or check "Years" | |||
| Infectious Disease Markers | no | no | Donor sex | female,male | Donor sex | female,male | |||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Who is being tested for IDMs? | donor IDM (marrow or PBSC),cord blood unit IDM,maternal IDM (cord blood) | Who is being tested for IDMs? | donor IDM (marrow or PBSC),cord blood unit IDM,maternal IDM (cord blood) | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | HBsAg: (hepatitis B surface antigen) | Non-reactive,Not done,Reactive | HBsAg: (hepatitis B surface antigen) | Non-reactive,Not done,Reactive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Anti HBc: (hepatitis B core antibody) | Non-reactive,Not done,Reactive | Anti HBc: (hepatitis B core antibody) | Non-reactive,Not done,Reactive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | FDA licensed NAAT testing for HBV | Negative,Not done,Positive | FDA licensed NAAT testing for HBV | Negative,Not done,Positive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Anti-HCV: (hepatitis C antibody) | Non-reactive,Not done,Reactive | Anti-HCV: (hepatitis C antibody) | Non-reactive,Not done,Reactive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | FDA licensed NAAT testing for HCV | Negative,Not done,Positive | FDA licensed NAAT testing for HCV | Negative,Not done,Positive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | HIV-1 p24 antigen | Non-reactive,Not done,Not reported,Reactive | HIV-1 p24 antigen | Non-reactive,Not done,Not reported,Reactive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | FDA licensed NAAT testing for HIV-1 | Negative,Not done,Positive | FDA licensed NAAT testing for HIV-1 | Negative,Not done,Positive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Anti-HIV 1 and anti-HIV 2*: (antibodies to Human Immunodeficiency Viruses) | Non-reactive,Not done,Not reported,Reactive | Anti-HIV 1 and anti-HIV 2*: (antibodies to Human Immunodeficiency Viruses) | Non-reactive,Not done,Not reported,Reactive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Chagas testing | Negative,Not Done,Positive | Chagas testing | Negative,Not Done,Positive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Anti-HSV (Herpes simplex virus antibody) | Negative,Not Done,Positive | Anti-HSV (Herpes simplex virus antibody) | Negative,Not Done,Positive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Anti-EBV (Epstein-Barr virus antibody) | Inconclusive,Negative,Not done,Positive | Anti-EBV (Epstein-Barr virus antibody) | Inconclusive,Negative,Not done,Positive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Anti-VZV (Varicella zoster virus antibody) | Negative,Not Done,Positive | Anti-VZV (Varicella zoster virus antibody) | Negative,Not Done,Positive | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Other infectious disease marker, specify | no,yes | Other infectious disease marker, specify | no,yes | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Specify test and method: | open text | Specify test and method: | open text | ||
| Infectious Disease Markers | Non NMDP Allogeneic or syngeneic Donor or Non NMDP Cord Blood Unit Information | yes | no | Specify test results: | open text | Specify test results: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Registry donor ID: | open text | Registry donor ID: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Non-NMDP cord blood unit ID: | open text | Non-NMDP cord blood unit ID: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Global Registration Identifier for Donors (GRID) | open text | Global Registration Identifier for Donors (GRID) | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | ISBT DIN: | open text | ISBT DIN: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Registry or UCB Bank ID | (A) Austrian Bone Marrow Donors,(ACB) Austrian Cord Blood Registry,(ACCB) StemCyte, Inc,(AE) Emirates Bone Marrow Donor Registry,(AM) Armenian Bone Marrow Donor Registry Charitable Trust,(AOCB) University of Colorado Cord Blood Bank,(AR) Argentine CPH Donors Registry,(ARCB) BANCEL - Argentina Cord Blood Bank,(AUCB) Australian Cord Blood Registry,(AUS) Australian / New Zealand Bone Marrow Donor Registry,(B) Marrow Donor Program Belgium,(BCB) Belgium Cord Blood Registry,(BG) Bulgarian Bone Marrow Donor Registry,(BR) INCA/REDOMO,(BSCB) British Bone Marrow Registry - Cord Blood,(CB) Cord Blood Registry,(CH) Swiss BloodStem Cells - Adult Donors,(CHCB) Swiss Blood Stem Cells - Cord Blood,(CKCB) Celgene Cord Blood Bank,(CN) China Marrow Donor Program (CMDP),(CNCB) Shan Dong Cord Blood Bank,(CND) Canadian Blood Services Bone Marrow Donor Registry,(CS2) Czech National Marrow Donor Registry,(CSCR) Czech Stem Cells Registry,(CY) Cyprus Paraskevaidio Bone Marrow Donor Registry,(CY2) The Cyprus Bone Marrow Donor Registry,(D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors,(DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood,(DK) The Danish Bone Marrow Donor Registry,(DK2) Bone Marrow Donors Copenhagen (BMDC),(DUCB) German Branch of the European Cord Blood Bank,(E) REDMO,(ECB) Spanish Cord Blood Registry,(F) France Greffe de Moelle - Adult Donors,(FCB) France Greffe de Moelle - Cord Blood,(FI) Finnish Bone Marrow Donor Registry,(FICB) Finnish Cord Blood Registry,(GB) The Anthony Nolan Trust,(GB3) Welsh Bone Marrow Donor Registry,(GB4) British Bone Marrow Registry,(GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece,(GRCB) Michigan Community Blood Centers Cord Blood Bank,(H) Hungarian Bone Marrow Donor Registry,(HEM) Hema-Quebec,(HK) Hong Kong Bone Marrow Donor Registry,(HR) Croatian Bone Marrow Donor Registry,(I) Italian Bone Marrow Donor Registry,(I3CB) Sheba Medical Centre Cord Blood Registry,(ICB) Italian Cord Blood Bank Network,(IL) Hadassah BMDR,(IL2) Ezer Mizion Bone Marrow Donor Registry,(IL3) Sheba Medical Center Donor Registry,(ILCB) Isreal Cord Blood Bank,(IN) Asian Indian Donor Marrow Registry,(IN2) Dept. of Transfusion Medicine,(IRL) The Irish Unrelated Bone Marrow Panel,(JP) Japan Marrow Donor Program,(KR) Korea Marrow Donor Program,(LT) Lithuanian National Bone Marrow Donor Registry,(LVCB) Leuven Cord Blood Bank,(MACB) Victoria Angel Registry of Hope,(MX) Mexican Bone Marrow Donor Registry,(N) The Norwegian Bone Marrow Donor Registry,(NL) Europdonor Foundation- Adult Donors,(NLCB) Europdonor Foundation - Cord Blood,(NYCB) National Cord Blood Program, New York Blood Center,(OTH) Other Registry,(P) Portuguese Bone Marrow Donors Registry,(PL) National Polish Bone Marrow Registry,(PL2) Unrelated Bone Marrow Donor Registry -Adult Donors,(PL3) Against Leukemia Foundation Marrow Donor Registry,(PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry,(PL5) Polish Central Bone Marrow Donor Registry - Adult Donors,(PMCB) Elie Katz Umbilical Cord Blood Program,(R) Russian Bone Marrow Donor Registry,(R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells,(S) Tobias Registry of Swedish Bone Marrow Donors,(SG) Singapore Bone Marrow Donor Programme (BMDP),(SK) Slovak National Bone Marrow Donor Registry,(SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry,(SLCBB) St Louis Cord Blood Bank,(SLO) Slovenia Donor,(SM) San Marino Bone Marrow Donor Registry,(T1CB) TRAN - Cord Blood,(TACB) StemCyte, Inc. Taiwan,(TECB) Healthbanks Biotech, Co., Ltd,(TH) Thai Stem Cell Donor Registry (TSCDR),(TOCB) Tokyo Cord Blood Bank,(TPCB) BIONET / BabyBanks,(TRAN) TRAN - Adult Donors,(TRIS) Bone Marrow Bank of Istanbul Medical Faculty,(TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors,(TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood,(U1CB) National Marrow Donor Program - Cord Blood,(USA1) National Marrow Donor Program - Adult Donors,(USA2) America Bone Marrow Donor Registry,(UY) SINDOME,(VIAC) Viacord,(W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood,(WACB) Unrelated Bone Marrow Donor Registry - Cord Blood,(ZA) South African Bone Marrow Registry | Registry or UCB Bank ID | (A) Austrian Bone Marrow Donors,(ACB) Austrian Cord Blood Registry,(ACCB) StemCyte, Inc,(AE) Emirates Bone Marrow Donor Registry,(AM) Armenian Bone Marrow Donor Registry Charitable Trust,(AOCB) University of Colorado Cord Blood Bank,(AR) Argentine CPH Donors Registry,(ARCB) BANCEL - Argentina Cord Blood Bank,(AUCB) Australian Cord Blood Registry,(AUS) Australian / New Zealand Bone Marrow Donor Registry,(B) Marrow Donor Program Belgium,(BCB) Belgium Cord Blood Registry,(BG) Bulgarian Bone Marrow Donor Registry,(BR) INCA/REDOMO,(BSCB) British Bone Marrow Registry - Cord Blood,(CB) Cord Blood Registry,(CH) Swiss BloodStem Cells - Adult Donors,(CHCB) Swiss Blood Stem Cells - Cord Blood,(CKCB) Celgene Cord Blood Bank,(CN) China Marrow Donor Program (CMDP),(CNCB) Shan Dong Cord Blood Bank,(CND) Canadian Blood Services Bone Marrow Donor Registry,(CS2) Czech National Marrow Donor Registry,(CSCR) Czech Stem Cells Registry,(CY) Cyprus Paraskevaidio Bone Marrow Donor Registry,(CY2) The Cyprus Bone Marrow Donor Registry,(D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors,(DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood,(DK) The Danish Bone Marrow Donor Registry,(DK2) Bone Marrow Donors Copenhagen (BMDC),(DUCB) German Branch of the European Cord Blood Bank,(E) REDMO,(ECB) Spanish Cord Blood Registry,(F) France Greffe de Moelle - Adult Donors,(FCB) France Greffe de Moelle - Cord Blood,(FI) Finnish Bone Marrow Donor Registry,(FICB) Finnish Cord Blood Registry,(GB) The Anthony Nolan Trust,(GB3) Welsh Bone Marrow Donor Registry,(GB4) British Bone Marrow Registry,(GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece,(GRCB) Michigan Community Blood Centers Cord Blood Bank,(H) Hungarian Bone Marrow Donor Registry,(HEM) Hema-Quebec,(HK) Hong Kong Bone Marrow Donor Registry,(HR) Croatian Bone Marrow Donor Registry,(I) Italian Bone Marrow Donor Registry,(I3CB) Sheba Medical Centre Cord Blood Registry,(ICB) Italian Cord Blood Bank Network,(IL) Hadassah BMDR,(IL2) Ezer Mizion Bone Marrow Donor Registry,(IL3) Sheba Medical Center Donor Registry,(ILCB) Isreal Cord Blood Bank,(IN) Asian Indian Donor Marrow Registry,(IN2) Dept. of Transfusion Medicine,(IRL) The Irish Unrelated Bone Marrow Panel,(JP) Japan Marrow Donor Program,(KR) Korea Marrow Donor Program,(LT) Lithuanian National Bone Marrow Donor Registry,(LVCB) Leuven Cord Blood Bank,(MACB) Victoria Angel Registry of Hope,(MX) Mexican Bone Marrow Donor Registry,(N) The Norwegian Bone Marrow Donor Registry,(NL) Europdonor Foundation- Adult Donors,(NLCB) Europdonor Foundation - Cord Blood,(NYCB) National Cord Blood Program, New York Blood Center,(OTH) Other Registry,(P) Portuguese Bone Marrow Donors Registry,(PL) National Polish Bone Marrow Registry,(PL2) Unrelated Bone Marrow Donor Registry -Adult Donors,(PL3) Against Leukemia Foundation Marrow Donor Registry,(PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry,(PL5) Polish Central Bone Marrow Donor Registry - Adult Donors,(PMCB) Elie Katz Umbilical Cord Blood Program,(R) Russian Bone Marrow Donor Registry,(R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells,(S) Tobias Registry of Swedish Bone Marrow Donors,(SG) Singapore Bone Marrow Donor Programme (BMDP),(SK) Slovak National Bone Marrow Donor Registry,(SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry,(SLCBB) St Louis Cord Blood Bank,(SLO) Slovenia Donor,(SM) San Marino Bone Marrow Donor Registry,(T1CB) TRAN - Cord Blood,(TACB) StemCyte, Inc. Taiwan,(TECB) Healthbanks Biotech, Co., Ltd,(TH) Thai Stem Cell Donor Registry (TSCDR),(TOCB) Tokyo Cord Blood Bank,(TPCB) BIONET / BabyBanks,(TRAN) TRAN - Adult Donors,(TRIS) Bone Marrow Bank of Istanbul Medical Faculty,(TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors,(TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood,(U1CB) National Marrow Donor Program - Cord Blood,(USA1) National Marrow Donor Program - Adult Donors,(USA2) America Bone Marrow Donor Registry,(UY) SINDOME,(VIAC) Viacord,(W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood,(WACB) Unrelated Bone Marrow Donor Registry - Cord Blood,(ZA) South African Bone Marrow Registry | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Donor DOB: | YYYY/MM/DD | Donor DOB: | YYYY/MM/DD | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Donor age: | open text, check "Months" or check "Years" | Donor age: | open text, check "Months" or check "Years" | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Donor sex | female,male | Donor sex | female,male | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specify the person for whom this typing is being done | Donor,Recipient-final typing | Specify the person for whom this typing is being done | Donor,Recipient-final typing | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Was documentation submitted to the CIBMTR (e.g. lab report) | No,Yes | Was documentation submitted to the CIBMTR (e.g. lab report) | No,Yes | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Locus A | Known,Unknown | Locus A | Known,Unknown | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | First A* allele designations: | open text | First A* allele designations: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Second A* allele designations: | open text | Second A* allele designations: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Locus B | Known,Unknown | Locus B | Known,Unknown | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | First B* allele designations: | open text | First B* allele designations: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Second B* allele designations: | open text | Second B* allele designations: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Locus C | Known,Unknown | Locus C | Known,Unknown | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | First C* allele designations: | open text | First C* allele designations: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Second C* allele designations: | open text | Second C* allele designations: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Locus DRB1 | Known,Unknown | Locus DRB1 | Known,Unknown | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | First DRB1* allele designations: | open text | First DRB1* allele designations: | open text | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Second DRB1* allele designations: | open text | Second DRB1* allele designations: | open text | ||
| Confirmation of HLA Typing | no | no | Locus DRB3 | Known,Unknown | Locus DRB3 | Known,Unknown | |||
| Confirmation of HLA Typing | no | no | First DRB3* allele designations: | open text | First DRB3* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Second DRB3* allele designations: | open text | Second DRB3* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Locus DRB4 | Known,Unknown | Locus DRB4 | Known,Unknown | |||
| Confirmation of HLA Typing | no | no | First DRB4* allele designations: | open text | First DRB4* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Second DRB4* allele designations: | open text | Second DRB4* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Locus DRB5 | Known,Unknown | Locus DRB5 | Known,Unknown | |||
| Confirmation of HLA Typing | no | no | First DRB5* allele designations: | open text | First DRB5* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Second DRB5* allele designations: | open text | Second DRB5* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Locus DQB1 | Known,Unknown | Locus DQB1 | Known,Unknown | |||
| Confirmation of HLA Typing | no | no | First DQB1* allele designations: | open text | First DQB1* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Second DQB1* allele designations: | open text | Second DQB1* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Locus DPB1 | Known,Unknown | Locus DPB1 | Known,Unknown | |||
| Confirmation of HLA Typing | no | no | First DPB1* allele designations: | open text | First DPB1* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Second DPB1* allele designations: | open text | Second DPB1* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Locus DQA1 | Known,Unknown | Locus DQA1 | Known,Unknown | |||
| Confirmation of HLA Typing | no | no | First DQA1* allele designations: | open text | First DQA1* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Second DQA1* allele designations: | open text | Second DQA1* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Locus DPA1 | Known,Unknown | Locus DPA1 | Known,Unknown | |||
| Confirmation of HLA Typing | no | no | First DPA1* allele designations: | open text | First DPA1* allele designations: | open text | |||
| Confirmation of HLA Typing | no | no | Second DPA1* allele designations: | open text | Second DPA1* allele designations: | open text | |||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | A Antigens. Number of antigens provided | one,two | A Antigens. Number of antigens provided | one,two | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 1st antigen | A1,A10,A11,A19,A2,A203,A210,A23(9),A24(9),A2403,A25(10),A26(10),A28,A29(19),A3,A30(19),A31(19),A32(19),A33(19),A34(10),A36,A43,A66(10),A68(28),A69(28),A74(19),A80,A9,AX | Specificity – 1st antigen | A1,A10,A11,A19,A2,A203,A210,A23(9),A24(9),A2403,A25(10),A26(10),A28,A29(19),A3,A30(19),A31(19),A32(19),A33(19),A34(10),A36,A43,A66(10),A68(28),A69(28),A74(19),A80,A9,AX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 2nd antigen | A1,A10,A11,A19,A2,A203,A210,A23(9),A24(9),A2403,A25(10),A26(10),A28,A29(19),A3,A30(19),A31(19),A32(19),A33(19),A34(10),A36,A43,A66(10),A68(28),A69(28),A74(19),A80,A9,AX | Specificity – 2nd antigen | A1,A10,A11,A19,A2,A203,A210,A23(9),A24(9),A2403,A25(10),A26(10),A28,A29(19),A3,A30(19),A31(19),A32(19),A33(19),A34(10),A36,A43,A66(10),A68(28),A69(28),A74(19),A80,A9,AX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | B Antigens. Number of antigens provided | one,two | B Antigens. Number of antigens provided | one,two | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 1st antigen | B12,B13,B14,B15,B16,B17,B18,B21,B22,B27,B2708,B35,B37,B38(16),B39(16),B3901,B3902,B40,B4005,B41,B42,B44(12),B45(12),B46,B47,B48,B49(21),B5,B50(21),B51(5),B5102,B5103,B52(5),B53,B54(22),B55(22),B56(22),B57(17),B58(17),B59,B60(40),B61(40),B62(15),B63(15),B64(14),B65(14),B67,B7,B70,B703,B71(70),B72(70),B73,B75(15),B76(15),B77(15),B78,B8,B81,B82,BX | Specificity – 1st antigen | B12,B13,B14,B15,B16,B17,B18,B21,B22,B27,B2708,B35,B37,B38(16),B39(16),B3901,B3902,B40,B4005,B41,B42,B44(12),B45(12),B46,B47,B48,B49(21),B5,B50(21),B51(5),B5102,B5103,B52(5),B53,B54(22),B55(22),B56(22),B57(17),B58(17),B59,B60(40),B61(40),B62(15),B63(15),B64(14),B65(14),B67,B7,B70,B703,B71(70),B72(70),B73,B75(15),B76(15),B77(15),B78,B8,B81,B82,BX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 2nd antigen | B12,B13,B14,B15,B16,B17,B18,B21,B22,B27,B2708,B35,B37,B38(16),B39(16),B3901,B3902,B40,B4005,B41,B42,B44(12),B45(12),B46,B47,B48,B49(21),B5,B50(21),B51(5),B5102,B5103,B52(5),B53,B54(22),B55(22),B56(22),B57(17),B58(17),B59,B60(40),B61(40),B62(15),B63(15),B64(14),B65(14),B67,B7,B70,B703,B71(70),B72(70),B73,B75(15),B76(15),B77(15),B78,B8,B81,B82,BX | Specificity – 2nd antigen | B12,B13,B14,B15,B16,B17,B18,B21,B22,B27,B2708,B35,B37,B38(16),B39(16),B3901,B3902,B40,B4005,B41,B42,B44(12),B45(12),B46,B47,B48,B49(21),B5,B50(21),B51(5),B5102,B5103,B52(5),B53,B54(22),B55(22),B56(22),B57(17),B58(17),B59,B60(40),B61(40),B62(15),B63(15),B64(14),B65(14),B67,B7,B70,B703,B71(70),B72(70),B73,B75(15),B76(15),B77(15),B78,B8,B81,B82,BX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | C Antigens. Number of antigens provided | one,two | C Antigens. Number of antigens provided | one,two | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 1st antigen | Cw1,Cw10(W3),Cw2,Cw3,Cw4,Cw5,Cw6,Cw7,Cw8,Cw9(W3),CX | Specificity – 1st antigen | Cw1,Cw10(W3),Cw2,Cw3,Cw4,Cw5,Cw6,Cw7,Cw8,Cw9(W3),CX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 2nd antigen | Cw1,Cw10(W3),Cw2,Cw3,Cw4,Cw5,Cw6,Cw7,Cw8,Cw9(W3),CX | Specificity – 2nd antigen | Cw1,Cw10(W3),Cw2,Cw3,Cw4,Cw5,Cw6,Cw7,Cw8,Cw9(W3),CX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity Bw4 present? | no,yes | Specificity Bw4 present? | no,yes | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity Bw6 present? | no,yes | Specificity Bw6 present? | no,yes | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | DR Antigens. Number of antigens provided | one,two | DR Antigens. Number of antigens provided | one,two | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 1st antigen | DR1,DR10,DR103,DR11(5),DR12(5),DR13(6),DR14(6),DR1403,DR1404,DR15(2),DR16(2),DR17(3),DR18(3),DR2,DR3,DR4,DR5,DR6,DR7,DR8,DR9,DRX | Specificity – 1st antigen | DR1,DR10,DR103,DR11(5),DR12(5),DR13(6),DR14(6),DR1403,DR1404,DR15(2),DR16(2),DR17(3),DR18(3),DR2,DR3,DR4,DR5,DR6,DR7,DR8,DR9,DRX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 2nd antigen | DR1,DR10,DR103,DR11(5),DR12(5),DR13(6),DR14(6),DR1403,DR1404,DR15(2),DR16(2),DR17(3),DR18(3),DR2,DR3,DR4,DR5,DR6,DR7,DR8,DR9,DRX | Specificity – 2nd antigen | DR1,DR10,DR103,DR11(5),DR12(5),DR13(6),DR14(6),DR1403,DR1404,DR15(2),DR16(2),DR17(3),DR18(3),DR2,DR3,DR4,DR5,DR6,DR7,DR8,DR9,DRX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity DR51 present? | no,yes | Specificity DR51 present? | no,yes | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity DR52 present? | no,yes | Specificity DR52 present? | no,yes | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity DR53 present? | no,yes | Specificity DR53 present? | no,yes | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | DQ Antigens. Number of antigens provided | one,two | DQ Antigens. Number of antigens provided | one,two | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 1st antigen | DQ1,DQ2,DQ3,DQ4,DQ5(1),DQ6(1),DQ7(3),DQ8(3),DQ9(3),DQX | Specificity – 1st antigen | DQ1,DQ2,DQ3,DQ4,DQ5(1),DQ6(1),DQ7(3),DQ8(3),DQ9(3),DQX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 2nd antigen | DQ1,DQ2,DQ3,DQ4,DQ5(1),DQ6(1),DQ7(3),DQ8(3),DQ9(3),DQX | Specificity – 2nd antigen | DQ1,DQ2,DQ3,DQ4,DQ5(1),DQ6(1),DQ7(3),DQ8(3),DQ9(3),DQX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | DP Antigens. Number of antigens provided | one,two | DP Antigens. Number of antigens provided | one,two | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 1st antigen | DPw1,DPw2,DPw3,DPw4,DPw5,DPw6,DPX | Specificity – 1st antigen | DPw1,DPw2,DPw3,DPw4,DPw5,DPw6,DPX | ||
| Confirmation of HLA Typing | Non NMDP Allogeneic or syngeneic Donor / Recipient or Non NMDP Cord Blood Unit Information | yes | no | Specificity – 2nd antigen | DPw1,DPw2,DPw3,DPw4,DPw5,DPw6,DPX | Specificity – 2nd antigen | DPw1,DPw2,DPw3,DPw4,DPw5,DPw6,DPX | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | no | no | HCT type (check only one) | Allogeneic, related,Allogeneic, unrelated,Autologous | HCT type (check only one) | Allogeneic, related,Allogeneic, unrelated,Autologous | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Product type (check only one) | Bone marrow,Other product,PBSC,Single cord blood unit | Product type | Bone marrow,Other product,PBSC,Single cord blood unit | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify: | open text | Specify: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | NMDP Product | No,Yes | NMDP Product | No,Yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | NMDP cord blood unit ID: | open text | NMDP cord blood unit ID: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | NMDP donor ID: | open text | NMDP donor ID: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Registry donor ID: | open text | Registry donor ID: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Non-NMDP cord blood unit ID: | open text | Non-NMDP cord blood unit ID: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Global Registration Identifier for Donors (GRID) | open text | Global Registration Identifier for Donors (GRID) | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | ISBT DIN: | open text | ISBT DIN: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Registry or UCB Bank ID | (A) Austrian Bone Marrow Donors,(ACB) Austrian Cord Blood Registry,(ACCB) StemCyte, Inc,(AE) Emirates Bone Marrow Donor Registry,(AM) Armenian Bone Marrow Donor Registry Charitable Trust,(AOCB) University of Colorado Cord Blood Bank,(AR) Argentine CPH Donors Registry,(ARCB) BANCEL - Argentina Cord Blood Bank,(AUCB) Australian Cord Blood Registry,(AUS) Australian / New Zealand Bone Marrow Donor Registry,(B) Marrow Donor Program Belgium,(BCB) Belgium Cord Blood Registry,(BG) Bulgarian Bone Marrow Donor Registry,(BR) INCA/REDOMO,(BSCB) British Bone Marrow Registry - Cord Blood,(CB) Cord Blood Registry,(CH) Swiss BloodStem Cells - Adult Donors,(CHCB) Swiss Blood Stem Cells - Cord Blood,(CKCB) Celgene Cord Blood Bank,(CN) China Marrow Donor Program (CMDP),(CNCB) Shan Dong Cord Blood Bank,(CND) Canadian Blood Services Bone Marrow Donor Registry,(CS2) Czech National Marrow Donor Registry,(CSCR) Czech Stem Cells Registry,(CY) Cyprus Paraskevaidio Bone Marrow Donor Registry,(CY2) The Cyprus Bone Marrow Donor Registry,(D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors,(DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood,(DK) The Danish Bone Marrow Donor Registry,(DK2) Bone Marrow Donors Copenhagen (BMDC),(DUCB) German Branch of the European Cord Blood Bank,(E) REDMO,(ECB) Spanish Cord Blood Registry,(F) France Greffe de Moelle - Adult Donors,(FCB) France Greffe de Moelle - Cord Blood,(FI) Finnish Bone Marrow Donor Registry,(FICB) Finnish Cord Blood Registry,(GB) The Anthony Nolan Trust,(GB3) Welsh Bone Marrow Donor Registry,(GB4) British Bone Marrow Registry,(GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece,(GRCB) Michigan Community Blood Centers Cord Blood Bank,(H) Hungarian Bone Marrow Donor Registry,(HEM) Hema-Quebec,(HK) Hong Kong Bone Marrow Donor Registry,(HR) Croatian Bone Marrow Donor Registry,(I) Italian Bone Marrow Donor Registry,(I3CB) Sheba Medical Centre Cord Blood Registry,(ICB) Italian Cord Blood Bank Network,(IL) Hadassah BMDR,(IL2) Ezer Mizion Bone Marrow Donor Registry,(IL3) Sheba Medical Center Donor Registry,(ILCB) Isreal Cord Blood Bank,(IN) Asian Indian Donor Marrow Registry,(IN2) Dept. of Transfusion Medicine,(IRL) The Irish Unrelated Bone Marrow Panel,(JP) Japan Marrow Donor Program,(KR) Korea Marrow Donor Program,(LT) Lithuanian National Bone Marrow Donor Registry,(LVCB) Leuven Cord Blood Bank,(MACB) Victoria Angel Registry of Hope,(MX) Mexican Bone Marrow Donor Registry,(N) The Norwegian Bone Marrow Donor Registry,(NL) Europdonor Foundation- Adult Donors,(NLCB) Europdonor Foundation - Cord Blood,(NYCB) National Cord Blood Program, New York Blood Center,(OTH) Other Registry,(P) Portuguese Bone Marrow Donors Registry,(PL) National Polish Bone Marrow Registry,(PL2) Unrelated Bone Marrow Donor Registry -Adult Donors,(PL3) Against Leukemia Foundation Marrow Donor Registry,(PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry,(PL5) Polish Central Bone Marrow Donor Registry - Adult Donors,(PMCB) Elie Katz Umbilical Cord Blood Program,(R) Russian Bone Marrow Donor Registry,(R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells,(S) Tobias Registry of Swedish Bone Marrow Donors,(SG) Singapore Bone Marrow Donor Programme (BMDP),(SK) Slovak National Bone Marrow Donor Registry,(SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry,(SLCBB) St Louis Cord Blood Bank,(SLO) Slovenia Donor,(SM) San Marino Bone Marrow Donor Registry,(T1CB) TRAN - Cord Blood,(TACB) StemCyte, Inc. Taiwan,(TECB) Healthbanks Biotech, Co., Ltd,(TH) Thai Stem Cell Donor Registry (TSCDR),(TOCB) Tokyo Cord Blood Bank,(TPCB) BIONET / BabyBanks,(TRAN) TRAN - Adult Donors,(TRIS) Bone Marrow Bank of Istanbul Medical Faculty,(TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors,(TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood,(U1CB) National Marrow Donor Program - Cord Blood,(USA1) National Marrow Donor Program - Adult Donors,(USA2) America Bone Marrow Donor Registry,(UY) SINDOME,(VIAC) Viacord,(W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood,(WACB) Unrelated Bone Marrow Donor Registry - Cord Blood,(ZA) South African Bone Marrow Registry | Registry or UCB Bank ID | (A) Austrian Bone Marrow Donors,(ACB) Austrian Cord Blood Registry,(ACCB) StemCyte, Inc,(AE) Emirates Bone Marrow Donor Registry,(AM) Armenian Bone Marrow Donor Registry Charitable Trust,(AOCB) University of Colorado Cord Blood Bank,(AR) Argentine CPH Donors Registry,(ARCB) BANCEL - Argentina Cord Blood Bank,(AUCB) Australian Cord Blood Registry,(AUS) Australian / New Zealand Bone Marrow Donor Registry,(B) Marrow Donor Program Belgium,(BCB) Belgium Cord Blood Registry,(BG) Bulgarian Bone Marrow Donor Registry,(BR) INCA/REDOMO,(BSCB) British Bone Marrow Registry - Cord Blood,(CB) Cord Blood Registry,(CH) Swiss BloodStem Cells - Adult Donors,(CHCB) Swiss Blood Stem Cells - Cord Blood,(CKCB) Celgene Cord Blood Bank,(CN) China Marrow Donor Program (CMDP),(CNCB) Shan Dong Cord Blood Bank,(CND) Canadian Blood Services Bone Marrow Donor Registry,(CS2) Czech National Marrow Donor Registry,(CSCR) Czech Stem Cells Registry,(CY) Cyprus Paraskevaidio Bone Marrow Donor Registry,(CY2) The Cyprus Bone Marrow Donor Registry,(D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors,(DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood,(DK) The Danish Bone Marrow Donor Registry,(DK2) Bone Marrow Donors Copenhagen (BMDC),(DUCB) German Branch of the European Cord Blood Bank,(E) REDMO,(ECB) Spanish Cord Blood Registry,(F) France Greffe de Moelle - Adult Donors,(FCB) France Greffe de Moelle - Cord Blood,(FI) Finnish Bone Marrow Donor Registry,(FICB) Finnish Cord Blood Registry,(GB) The Anthony Nolan Trust,(GB3) Welsh Bone Marrow Donor Registry,(GB4) British Bone Marrow Registry,(GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece,(GRCB) Michigan Community Blood Centers Cord Blood Bank,(H) Hungarian Bone Marrow Donor Registry,(HEM) Hema-Quebec,(HK) Hong Kong Bone Marrow Donor Registry,(HR) Croatian Bone Marrow Donor Registry,(I) Italian Bone Marrow Donor Registry,(I3CB) Sheba Medical Centre Cord Blood Registry,(ICB) Italian Cord Blood Bank Network,(IL) Hadassah BMDR,(IL2) Ezer Mizion Bone Marrow Donor Registry,(IL3) Sheba Medical Center Donor Registry,(ILCB) Isreal Cord Blood Bank,(IN) Asian Indian Donor Marrow Registry,(IN2) Dept. of Transfusion Medicine,(IRL) The Irish Unrelated Bone Marrow Panel,(JP) Japan Marrow Donor Program,(KR) Korea Marrow Donor Program,(LT) Lithuanian National Bone Marrow Donor Registry,(LVCB) Leuven Cord Blood Bank,(MACB) Victoria Angel Registry of Hope,(MX) Mexican Bone Marrow Donor Registry,(N) The Norwegian Bone Marrow Donor Registry,(NL) Europdonor Foundation- Adult Donors,(NLCB) Europdonor Foundation - Cord Blood,(NYCB) National Cord Blood Program, New York Blood Center,(OTH) Other Registry,(P) Portuguese Bone Marrow Donors Registry,(PL) National Polish Bone Marrow Registry,(PL2) Unrelated Bone Marrow Donor Registry -Adult Donors,(PL3) Against Leukemia Foundation Marrow Donor Registry,(PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry,(PL5) Polish Central Bone Marrow Donor Registry - Adult Donors,(PMCB) Elie Katz Umbilical Cord Blood Program,(R) Russian Bone Marrow Donor Registry,(R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells,(S) Tobias Registry of Swedish Bone Marrow Donors,(SG) Singapore Bone Marrow Donor Programme (BMDP),(SK) Slovak National Bone Marrow Donor Registry,(SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry,(SLCBB) St Louis Cord Blood Bank,(SLO) Slovenia Donor,(SM) San Marino Bone Marrow Donor Registry,(T1CB) TRAN - Cord Blood,(TACB) StemCyte, Inc. Taiwan,(TECB) Healthbanks Biotech, Co., Ltd,(TH) Thai Stem Cell Donor Registry (TSCDR),(TOCB) Tokyo Cord Blood Bank,(TPCB) BIONET / BabyBanks,(TRAN) TRAN - Adult Donors,(TRIS) Bone Marrow Bank of Istanbul Medical Faculty,(TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors,(TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood,(U1CB) National Marrow Donor Program - Cord Blood,(USA1) National Marrow Donor Program - Adult Donors,(USA2) America Bone Marrow Donor Registry,(UY) SINDOME,(VIAC) Viacord,(W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood,(WACB) Unrelated Bone Marrow Donor Registry - Cord Blood,(ZA) South African Bone Marrow Registry | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Donor DOB: | YYYY/MM/DD | Donor DOB: | YYYY/MM/DD | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Donor age: | open text, check "Months" or check "Years" | Donor age: | open text, check "Months" or check "Years" | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Donor sex | open text, check "Months" or check "Years" | Donor sex | open text, check "Months" or check "Years" | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Allogeneic Donors | yes | no | Did the donor receive growth and mobilizing factors, prior to any stem cell harvest, to enhance the product collection for this HCT? | No,Yes | Did the donor receive growth and mobilizing factors, prior to any stem cell harvest, to enhance the product collection for this HCT? | No,Yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Allogeneic Donors | yes | no | Specify growth and mobilizing factor(s) (check all that apply) | G-CSF (filgrastim, Neupogen),Pegylated G-CSF(pegfilgrastim, Neulasta) , Plerixafor (Mozobil) Other growth or mobilizing factor(s) | Specify growth and mobilizing factor(s) (check all that apply) | G-CSF (filgrastim, Neupogen),Pegylated G-CSF(pegfilgrastim, Neulasta) , Plerixafor (Mozobil) Other growth or mobilizing factor(s) | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Allogeneic Donors | yes | no | Specify other growth or mobilizing factor(s): | open text | Specify other growth or mobilizing factor(s): | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Date of first collection for this mobilization: | YYYY/MM/DD | Date of first collection for this mobilization: | YYYY/MM/DD | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Were anticoagulants or other agents added to the product between collection and infusion? | No,Yes | Were anticoagulants or other agents added to the product between collection and infusion? | No,Yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify anticoagulant(s) or other agents (check all that apply) | Acid citrate dextrose (ACD, ACD-A), Citrate phosphate dextrose (CPD, CPD-A), Ethylenediaminetetraacetic acid (EDTA), Heparin, Other agent | Specify anticoagulant(s) or other agents (check all that apply) | Acid citrate dextrose (ACD, ACD-A), Citrate phosphate dextrose (CPD, CPD-A), Ethylenediaminetetraacetic acid (EDTA), Heparin, Other agent | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify other agent: | open text | Specify other agent: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Was this product collected off-site and shipped to your facility? | no,yes | Was this product collected off-site and shipped to your facility? | no,yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Date of receipt of product at your facility: | YYYY/MM/DD | Date of receipt of product at your facility: | YYYY/MM/DD | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Time of receipt of product (24-hour clock): | Hour:Minute Check standard time or check daylight savings | Time of receipt of product (24-hour clock): | Hour:Minute Check standard time or check daylight savings | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify the shipping environment of the product(s) | Room temperature, Cooled (refrigerator temperature, not frozen), Frozen (cyropreserved), Other shipping enfivronment | Change/Clarification of Response Options | Specify the shipping environment of the product(s) | Room temperature, Cooled (refrigerated gel pack, refrigerator temperature, not frozen), Frozen (cyropreserved), Other shipping enfivronment | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify other shipping environment: | open text | Specify other shipping environment: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Was there any indication that the environment within the shipper was outside the expected temperature range for this product at any time during shipment? | no,yes | Was there any indication that the environment within the shipper was outside the expected temperature range for this product at any time during shipment? | no,yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Were the secondary containers (e.g., insulated shipping containers and unit cassette) intact when they arrived at your center? | no,yes | Were the secondary containers (e.g., insulated shipping containers and unit cassette) intact when they arrived at your center? | no,yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Cord Blood Product Infusion | yes | no | Was the cord blood unit stored at your center prior to thawing? | no,yes | Was the cord blood unit stored at your center prior to thawing? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Cord Blood Product Infusion | yes | no | Specify the storage method used for the cord blood unit | Electric freezer,Liquid nitrogen,Vapor phase | Specify the storage method used for the cord blood unit | Electric freezer,Liquid nitrogen,Vapor phase | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Cord Blood Product Infusion | yes | no | Temperature during storage | < -150 0C , > -150 0C to < -135 0C , > -135 0C to < -80 0C, > -80 0C | Temperature during storage | < -150 0C , > -150 0C to < -135 0C , > -135 0C to < -80 0C, > -80 0C | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Date storage started: | YYYY/MM/DD | Date storage started: | YYYY/MM/DD | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Cord Blood Product Infusion | yes | no | Total nucleated cells: (Includes nucleated red and nucleated white cells) | _ _ _ _ . __ __ x 10 __ __ (Includes nucleated red and nucleated white cells) (Cord blood units only) | Total nucleated cells: (Includes nucleated red and nucleated white cells) | _ _ _ _ . __ __ x 10 __ __ (Includes nucleated red and nucleated white cells) (Cord blood units only) | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Cord Blood Product Infusion | yes | no | CD34+ cells | Done,Not done | CD34+ cells | Done,Not done | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Cord Blood Product Infusion | yes | no | Total number of CD34+ cells: | _ _ _ _ . __ __ x 10 __ __ | Total number of CD34+ cells: | _ _ _ _ . __ __ x 10 __ __ | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Was the product thawed from a cryopreserved state prior to infusion? | no,yes | Was the product thawed from a cryopreserved state prior to infusion? | no,yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Was the entire product thawed? | no,yes | Was the entire product thawed? | no,yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Cord Blood Product Infusion | yes | no | Specify the percent of the product that was thawed? (Cord Blood units only) | 20%,80%,Other percent | Specify the percent of the product that was thawed? (Cord Blood units only) | 20%,80%,Other percent | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | Cord Blood Product Infusion | yes | no | Specify other percent: | _ _% | Specify other percent: | _ _% | ||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Date thawing process initiated: | YYYY/MM/DD | Date thawing process initiated: | YYYY/MM/DD | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Time at initiation of thaw (24-hour clock): | Hour:Minute Check "standard time" or "check daylight savings time" | Time at initiation of thaw (24-hour clock): | Hour:Minute Check "standard time" or "check daylight savings time" | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Time of thaw completion: | Hour:Minute Check "standard time" or "check daylight savings time" | Time of thaw completion: | Hour:Minute Check "standard time" or "check daylight savings time" | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | What method was used to thaw the product? | Electric warmer,Other method,Waterbath | What method was used to thaw the product? | Electric warmer,Other method,Waterbath | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify other method: | open text | Specify other method: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Did any incidents or product complaints occur while preparing or thawing the product? | No,Yes | Did any incidents or product complaints occur while preparing or thawing the product? | No,Yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Was the product processed prior to infusion? | No,Yes | Was the product processed prior to infusion? | No,Yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify processing (check all that apply) | Buffy coat enriched (buffy coat preparation) ,Diluted,Plasma reduced,RBC reduced,Washed | Specify processing (check all that apply) | Buffy coat enriched (buffy coat preparation) ,Diluted,Plasma reduced,RBC reduced,Washed | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Was the product manipulated prior to infusion? | no,yes | Was the product manipulated prior to infusion? | no,yes | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify manipulations performed (check all that apply) | CD34 enriched (CD34+ selection), Ex-vivo expansion, Ex-vivo T-cell depetion, Genetic manipulation (gene transfer / transuction), Other cell manipulation | Specify manipulations performed (check all that apply) | CD34 enriched (CD34+ selection), Ex-vivo expansion, Ex-vivo T-cell depetion, Genetic manipulation (gene transfer / transuction), Other cell manipulation | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify antibodies used (check all that apply) | Alpha/beta antibody,Anti CD19,Anti CD3,Anti CD4,Anti CD45RA,Anti CD52,Anti CD8,Other antibody | Specify antibodies used (check all that apply) | Alpha/beta antibody,Anti CD19,Anti CD3,Anti CD4,Anti CD45RA,Anti CD52,Anti CD8,Other antibody | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify other antibody: | open text | Specify other antibody: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify T-cell depletion method | Antibody affinity column,Immunomagnetic beads,Other Method | Specify T-cell depletion method | Antibody affinity column,Immunomagnetic beads,Other Method | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify other method: | open text | Specify other method: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify other cell manipulation: | open text | Specify other cell manipulation: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Specify the timepoint in the product preparation phase that the product was analyzed | Product arrival (cord blood only) , At infusion (final quantity infused) | Specify the timepoint in the product preparation phase that the product was analyzed | Product arrival (cord blood only) , At infusion (final quantity infused) | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Date of product analysis: | YYYY/MM/DD | Date of product analysis: | YYYY/MM/DD | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total volume of product plus additives: | _ _ _ _ _ . _ ml | Total volume of product plus additives: | _ _ _ _ _ . _ ml | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total nucleated cells (TNC) | Done,Not done | Total nucleated cells (TNC) | Done,Not done | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total nucleated cells: | _ _ _ _ . __ __ x 10 __ __ | Total nucleated cells: | _ _ _ _ . __ __ x 10 __ __ | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of TNC | Done,Not done,Unknown | Viability of TNC | Done,Not done,Unknown | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of TNC: | _ _ _ % | Viability of TNC: | _ _ _ % | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing TNC viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing TNC viability | Flow cytometry based (7AAD, AOPI, AOEB),Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Specify other method: | open text | Specify other method: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Nucleated white blood cells | Done,Not done | Nucleated white blood cells | Done,Not done | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total number of nucleated white blood cells: | _ _ _ _ . __ __ x 10 __ __ | Total number of nucleated white blood cells: | _ _ _ _ . __ __ x 10 __ __ | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Mononuclear cells | Done,Not done | Mononuclear cells | Done,Not done | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total number of mononuclear cells: | _ _ _ _ . __ __ x 10 __ __ | Total number of mononuclear cells: | _ _ _ _ . __ __ x 10 __ __ | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Nucleated red blood cells | Done,Not done | Nucleated red blood cells | Done,Not done | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total number of nucleated red blood cells: | _ _ _ _ . __ __ x 10 __ __ | Total number of nucleated red blood cells: | _ _ _ _ . __ __ x 10 __ __ | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | CD34+ cells | Done,Not done | CD34+ cells | Done,Not done | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total number of CD34+ cells: | _ _ _ _ . __ __ x 10 __ __ | Total number of CD34+ cells: | _ _ _ _ . __ __ x 10 __ __ | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of CD34+ cells | Done,Not done,Unknown | Viability of CD34+ cells | Done,Not done,Unknown | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of CD34+ cells: | _ _ _% | Viability of CD34+ cells: | _ _ _% | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing CD34+ cell viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing CD34+ cell viability | Flow cytometry based (7AAD, AOPI, AOEB), Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Specify other method: | open text | Specify other method: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | CD3+ cells | Done,Not done | CD3+ cells | Done,Not done | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of CD3+ cells | Done,Not done,Unknown | Viability of CD3+ cells | Done,Not done,Unknown | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total number of CD3+ cells: | _ _ _ _ . __ __ x 10 __ __ | Total number of CD3+ cells: | _ _ _ _ . __ __ x 10 __ __ | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of CD3+ cells: | _ _ _% | Viability of CD3+ cells: | _ _ _% | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing CD3+ cell viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing CD3+ cell viability | Flow cytometry based (7AAD, AOPI, AOEB), Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Specify other method: | open text | Specify other method: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | CD3+CD4+ cells | Done,Not done | CD3+CD4+ cells | Done,Not done | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total number of CD3+CD4+ cells: | _ _ _ _ . __ __ x 10 __ __ | Total number of CD3+CD4+ cells: | _ _ _ _ . __ __ x 10 __ __ | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of CD3+CD4+ cells | Done,Not done,Unknown | Viability of CD3+CD4+ cells | Done,Not done,Unknown | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of CD3+CD4+ cells: | _ _ _% | Viability of CD3+CD4+ cells: | _ _ _% | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing CD3+CD4+ cell viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing CD3+CD4+ cell viability | Flow cytometry based (7AAD, AOPI, AOEB), Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Specify other method: | open text | Specify other method: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | CD3+CD8+ cells | Done,Not done | CD3+CD8+ cells | Done,Not done | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Total number of CD3+CD8+ cells: | _ _ _ _ *_ _ x 10 _ _ | Total number of CD3+CD8+ cells: | _ _ _ _ *_ _ x 10 _ _ | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of CD3+CD8+ cells | Done,Not done,Unknown | Viability of CD3+CD8+ cells | Done,Not done,Unknown | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Viability of CD3+CD8+ cells: | _ _ _% | Viability of CD3+CD8+ cells: | _ _ _% | |||
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing CD3+CD8+ cell viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing CD3+CD8+ cell viability | Flow cytometry based (7AAD, AOPI, AOEB), Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Specify other method: | open text | Specify other method: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Were the colony-forming units (CFU) assessed after thawing? (cord blood units only) | no,yes | Were the colony-forming units (CFU) assessed after thawing? (cord blood units only) | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Was there growth? | no,yes | Was there growth? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total CFU-GM | Done,Not done | Merged to Check all that Apply | Indicate which Assessments were Carried out (Check all that apply) | Total CFU-GM, Total CFU-GEMM, Total BFU-E | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total CFU-GM: | _ _ _ _ _.__x10__ __ | Total CFU-GM: | _ _ _ _ _.__x10__ __ | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total CFU-GEMM | Done,Not done | Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total CFU-GEMM: | _ _ _ _ _.__x10__ __ | Total CFU-GEMM: | _ _ _ _ _.__x10__ __ | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total BFU-E | Done,Not done | Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total BFU-E: | _ _ _ _ _.__x10__ __ | Total BFU-E: | _ _ _ _ _.__x10__ __ | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Were any positive cultures (for bacterial or fungal infections) obtained from the product at the transplant center? (complete for all cell products) | No,Pending,Unknown,Yes | Were any positive cultures (for bacterial or fungal infections) obtained from the product at the transplant center? (complete for all cell products) | No,Pending,Unknown,Yes | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Product Analysis | yes | yes | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methacillin Resistant), 179 Staphylococcus aureus (Methacillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Change/Clarification of Response Options | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methicillin Resistant), 179 Staphylococcus aureus (Methicillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Examples added or typographical errors corrected for clarification |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Product Analysis | yes | yes | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methacillin Resistant), 179 Staphylococcus aureus (Methacillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Change/Clarification of Response Options | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methicillin Resistant), 179 Staphylococcus aureus (Methicillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Examples added or typographical errors corrected for clarification |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Product Analysis | yes | yes | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methacillin Resistant), 179 Staphylococcus aureus (Methacillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Change/Clarification of Response Options | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methicillin Resistant), 179 Staphylococcus aureus (Methicillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Examples added or typographical errors corrected for clarification |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Product Analysis | yes | yes | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methacillin Resistant), 179 Staphylococcus aureus (Methacillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Change/Clarification of Response Options | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methicillin Resistant), 179 Staphylococcus aureus (Methicillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Examples added or typographical errors corrected for clarification |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Specify organism: | open text | Specify organism: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Date of this product infusion: | YYYY/MM/DD | Date of this product infusion: | YYYY/MM/DD | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Was the entire volume of received product infused? | no,yes | Was the entire volume of received product infused? | no,yes | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Specify what happened to the reserved portion | cryopreserved for future use,discarded,other fate | Specify what happened to the reserved portion | cryopreserved for future use,discarded,other fate | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Specify other fate: | open text | Specify other fate: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Time product infusion initiated (24-hour clock): | Hour:Minute Check "standard time" or "check daylight savings time" | Time product infusion initiated (24-hour clock): | Hour:Minute Check "standard time" or "check daylight savings time" | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Date infusion stopped: | YYYY/MM/DD | Date infusion stopped: | YYYY/MM/DD | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Time product infusion completed (24-hour clock): | Hour:Minute Check "standard time" or "check daylight savings time" | Time product infusion completed (24-hour clock): | Hour:Minute Check "standard time" or "check daylight savings time" | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Specify the route of product infusion (24-hour clock); | Intramedullary,Intravenous,Other route of infusion | Specify the route of product infusion (24-hour clock); | Intramedullary,Intravenous,Other route of infusion | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | no | yes | Specify other route of infusion: | open text | Specify other route of infusion: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Were there any adverse events or incidents associated with the stem cell infusion? | no,yes | Were there any adverse events or incidents associated with the stem cell infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Brachycardia | no,yes | Brachycardia | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Chest tightness / pain | no,yes | Chest tightness / pain | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Chills at time of infusion | no,yes | Chills at time of infusion | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Fever ≤ 103 °F within 24 hours of infusion | no,yes | Fever ≤ 103 °F within 24 hours of infusion | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Fever > 103° F within 24 hours of infusion | no,yes | Fever > 103° F within 24 hours of infusion | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Gross hemoglobinuria | no,yes | Gross hemoglobinuria | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Headache | no,yes | Headache | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Hives | no,yes | Hives | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Hypertension | no,yes | Hypertension | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Hypotension | no,yes | Hypotension | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Hypoxia requiring oxygen (O2) support | no,yes | Hypoxia requiring oxygen (O2) support | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Nausea | no,yes | Nausea | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Rigors, mild | no,yes | Rigors, mild | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Rigors, severe | no,yes | Rigors, severe | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Shortness of breath (SOB) | no,yes | Shortness of breath (SOB) | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Tachycardia | no,yes | Tachycardia | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Vomiting | no,yes | Vomiting | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Other expected AE | no,yes | Other expected AE | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Specify other expected AE: | open text | Specify other expected AE: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Other unexpected AE | no,yes | Other unexpected AE | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | Specify other unexpected AE: | open text | Specify other unexpected AE: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | no | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | In the Medical Director's judgment, was the adverse event a direct result of the infusion? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Was the donor ever pregnant? | Not applicable (male donor or cord blood unit) ,No,Unknown,Yes | Was the donor ever pregnant? | Not applicable (male donor or cord blood unit) ,No,Unknown,Yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Number of pregnancies | Known,Unknown | Number of pregnancies | Known,Unknown | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Specify number of pregnancies: | open text | Specify number of pregnancies: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Ethnicity (donor) | Hispanic or Latino,Not applicable (not a resident of the USA),Not Hispanic or Latino,Unknown | Ethnicity (donor) | Hispanic or Latino,Not applicable (not a resident of the USA),Not Hispanic or Latino,Unknown | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Race (donor) (check all that apply) | American Indian or Alaska Native,Asian,Black or African American,Not reported,Native Hawaiian or Other Pacific Islander,Unknown,White | Race (donor) (check all that apply) | American Indian or Alaska Native,Asian,Black or African American,Not reported,Native Hawaiian or Other Pacific Islander,Unknown,White | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Race detail (donor) (check all that apply) | African American,African (both parents born in Africa),South Asian,American Indian, South or Central America,Alaskan Native or Aleut,North American Indian,Black Caribbean,Caribbean Indian,Other White,Eastern European,Filipino (Pilipino),Guamanian,Hawaiian,Japanese,Korean,Mediterranean,Middle Eastern,North American,North Coast of Africa,Chinese,Northern European,Other Pacific Islander,Other Black,Samoan,Black South or Central American,Other Southeast Asian,Unknown,Vietnamese,White Caribbean,Western European,White South or Central American | Race detail (donor) (check all that apply) | African American,African (both parents born in Africa),South Asian,American Indian, South or Central America,Alaskan Native or Aleut,North American Indian,Black Caribbean,Caribbean Indian,Other White,Eastern European,Filipino (Pilipino),Guamanian,Hawaiian,Japanese,Korean,Mediterranean,Middle Eastern,North American,North Coast of Africa,Chinese,Northern European,Other Pacific Islander,Other Black,Samoan,Black South or Central American,Other Southeast Asian,Unknown,Vietnamese,White Caribbean,Western European,White South or Central American | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Was the donor a carrier for potentially transferable genetic diseases? | No,Yes | Was the donor a carrier for potentially transferable genetic diseases? | No,Yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Specify potentially transferable genetic disease (check all that apply) | Other hemoglobinopathy,Other disease,Sickle cell anemia,Thalassemia | Specify potentially transferable genetic disease (check all that apply) | Other hemoglobinopathy,Other disease,Sickle cell anemia,Thalassemia | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Specify other disease: | open text | Specify other disease: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Was the donor / product tested for other transferable genetic or clonal abnormalities? | No,Unknown,Yes | Was the donor / product tested for other transferable genetic or clonal abnormalities? | No,Unknown,Yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Clonal hematopoiesis of indeterminate potential (CHIP) | No,Yes | Clonal hematopoiesis of indeterminate potential (CHIP) | No,Yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | What was the method of testing used? | open text | What was the method of testing used? | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Monoclonal B-cell lymphocytosis | No,Yes | Monoclonal B-cell lymphocytosis | No,Yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Other transferable genetic or clonal abnormality | No,Yes | Other transferable genetic or clonal abnormality | No,Yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Non NMDP Allogeneic Donor / Infant Demographic Information | yes | no | Specify other transferable genetic or clonal abnormality: | open text | Specify other transferable genetic or clonal abnormality: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Did this donor have a central line placed? | no,yes | Did this donor have a central line placed? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Was the donor hospitalized (inpatient) during or after the collection? | no,yes | Was the donor hospitalized (inpatient) during or after the collection? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Did the donor experience any life-threatening complications during or after the collection? | no,yes | Did the donor experience any life-threatening complications during or after the collection? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Specify: | open text | Specify: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Did the allogeneic donor give one or more autologous transfusion units? | No,Yes | Did the allogeneic donor give one or more autologous transfusion units? | No,Yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Date of collection: | YYYY/MM/DD | Date of collection: | YYYY/MM/DD | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Number of units: | open text | Number of units: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Did the donor receive blood transfusions as a result of the collection? | Allogeneic transfusions,Autologous transfusions,No | Did the donor receive blood transfusions as a result of the collection? | Allogeneic transfusions,Autologous transfusions,No | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Specify number of autologous units: | open text | Specify number of autologous units: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Specify number of allogeneic units: | open text | Specify number of allogeneic units: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Did the donor die as a result of the collection? | no,yes | Did the donor die as a result of the collection? | no,yes | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | Allo Related Donor / Infant Demographic Information | yes | no | Specify cause of death: | open text | Specify cause of death: | open text | ||
| Hematopoietic Cellular Transplant (HCT) Infusion | no | yes | First Name (person completing form): | open text | First Name (person completing form): | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion | no | yes | Last Name: | open text | Last Name: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion | no | yes | E-mail address: | open text | E-mail address: | open text | |||
| Hematopoietic Cellular Transplant (HCT) Infusion | no | yes | Date: | YYYY/MM/DD | Date: | YYYY/MM/DD | |||
Sheet 3: Post-Transplant Periodic Inform
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Information Collection Domain: Post-Transplant Periodic Information Collection | ||||||||
| Information Collection Domain Sub-Type | Information Collection Domain Additional Sub Domain | Response required if Additional Sub Domain applies | Information Collection may be requested multiple times | Current Information Collection Data Element (if applicable) | Current Information Collection Data Element Response Option(s) | Information Collection update: | Proposed Information Collection Data Element (if applicable) | Proposed Information Collection Data Element Response Option(s) | Rationale for Information Collection Update |
| Post-Transplant Essential Data | no | yes | Sequence Number: | Auto Filled Field | Sequence Number: | Auto Filled Field | |||
| Post-Transplant Essential Data | no | yes | Date Received: | Auto Filled Field | Date Received: | Auto Filled Field | |||
| Post-Transplant Essential Data | no | yes | CIBMTR Center Number: | Auto Filled Field | CIBMTR Center Number: | Auto Filled Field | |||
| Post-Transplant Essential Data | no | yes | CIBMTR Research ID: | Auto Filled Field | CIBMTR Research ID: | Auto Filled Field | |||
| Post-Transplant Essential Data | no | yes | Event date: | Auto Filled Field created with CRID | Event date: | Auto Filled Field created with CRID | |||
| Post-Transplant Essential Data | no | yes | Visit | 100 day,1 year,2 years,> 2 years,6 months | Visit | 100 day,1 year,2 years,> 2 years,6 months | |||
| Post-Transplant Essential Data | no | yes | Specify: | open text | Specify: | open text | |||
| Post-Transplant Essential Data | no | yes | Date of actual contact with the recipient to determine medical status for this follow-up report: | YYYY/MM/DD | Date of actual contact with the recipient to determine medical status for this follow-up report: | YYYY/MM/DD | |||
| Post-Transplant Essential Data | no | yes | Specify the recipient's survival status at the date of last contact | Alive,Dead | Change/Clarification of Response Options | Specify the recipient's survival status at the date of last contact | Alive,Dead (Complete recipient death data) | Capture additional relevent disease information | |
| Post-Transplant Essential Data | no | yes | Did the recipient receive a subsequent HCT since the date of last report? | no,yes | Did the recipient receive a subsequent HCT since the date of last report? | no,yes | |||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Date of subsequent HCT: | YYYY/MM/DD | Date of subsequent HCT: | YYYY/MM/DD | ||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | What was the indication for subsequent HCT? | Graft failure / insufficient hematopoietic recovery,Insufficient chimerism,New malignancy (including PTLD and EBV lymphoma),Other,Persistent primary disease,Planned subsequent HCT, per protocol,Recurrent primary disease | What was the indication for subsequent HCT? | Graft failure / insufficient hematopoietic recovery,Insufficient chimerism,New malignancy (including PTLD and EBV lymphoma),Other,Persistent primary disease,Planned subsequent HCT, per protocol,Recurrent primary disease | ||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Specify other indication: | open text | Specify other indication: | open text | ||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Source of HSCs (check all that apply) | Allogeneic, related,Allogeneic, unrelated,Autologous | Source of HSCs (check all that apply) | Allogeneic, related,Allogeneic, unrelated,Autologous | ||
| Post-Transplant Essential Data | no | yes | Has the recipient received a cellular therapy since the date of last report? (e.g. CAR-T, DCI) | no,yes | Has the recipient received a cellular therapy since the date of last report? (e.g. CAR-T, DCI) | no,yes | |||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Addition of Information Requested |
Was this infusion a donor lymphocyte infusion (DLI)? | no,yes | Capture additional relevent disease information | ||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Addition of Information Requested |
Number of DLIs in this reporting period | __ __ | Capture additional relevent disease information | ||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Addition of Information Requested |
Are any of the products, associated with this course of cellular therapy, genetically modified? | no, yes | Capture additional relevent disease information | ||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Date of cellular therapy: | YYYY/MM/DD | Date of cellular therapy: | YYYY/MM/DD | ||
| Post-Transplant Essential Data | no | yes | Was there evidence of initial hematopoietic recovery? | No(ANC ≥ 500/mm3 was not achieved) ,Not applicable(ANC never dropped below 500/mm3 at any time after the start of the preparative regimen,Previously reported(recipient’s initial hematopoietic recovery was recorded on a previous report) ,Yes(ANC ≥ 500/mm3 achieved and sustained for 3 lab values) | Was there evidence of initial hematopoietic recovery? | No(ANC ≥ 500/mm3 was not achieved) ,Not applicable(ANC never dropped below 500/mm3 at any time after the start of the preparative regimen,Previously reported(recipient’s initial hematopoietic recovery was recorded on a previous report) ,Yes(ANC ≥ 500/mm3 achieved and sustained for 3 lab values) | |||
| Post-Transplant Essential Data | no | yes | Date ANC ≥ 500/mm³ (first of 3 lab values): | YYYY/MM/DD | Date ANC ≥ 500/mm³ (first of 3 lab values): | YYYY/MM/DD | |||
| Post-Transplant Essential Data | no | yes | Did late graft failure occur? | No,Yes | Did late graft failure occur? | No,Yes | |||
| Post-Transplant Essential Data | no | yes | Was an initial platelet count ≥ 20 x 109/L achieved? | No,Not applicable(Platelet count never dropped below 20 x 109/L) ,Previously reported(≥ 20 x 109/L was achieved and reported previously),Yes | Was an initial platelet count ≥ 20 x 109/L achieved? | No,Not applicable(Platelet count never dropped below 20 x 109/L) ,Previously reported(≥ 20 x 109/L was achieved and reported previously),Yes | |||
| Post-Transplant Essential Data | no | yes | Date platelets ≥ 20 x 109/L: | YYYY/MM/DD | Date platelets ≥ 20 x 109/L: | YYYY/MM/DD | |||
| Post-Transplant Essential Data | no | yes | Did acute GVHD develop since the date of last report? | No,Unknown,Yes | Did acute GVHD develop since the date of last report? | No,Unknown,Yes | |||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Date of acute GVHD diagnosis: | YYYY/MM/DD | Date of acute GVHD diagnosis: | YYYY/MM/DD | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Did acute GVHD persist since the date of last report? | No,Unknown,Yes | Did acute GVHD persist since the date of last report? | No,Unknown,Yes | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Overall grade of acute GVHD at diagnosis | I - Rash on ≤ 50% of skin, no liver or gut involvement II - Rash on > 50% of skin, bilirubin 2-3 mg/dL, or diarrhea 500 – 1000 mL/day or persistent nausea or vomiting III - Bilirubin 3-15 mg/dL, or gut stage 2-4 diarrhea > 1000 mL/day or severe abdominal pain with or without ileus IV - Generalized erythroderma with bullous formation, or bilirubin >15 mg/dL Not applicable (acute GVHD present but cannot be graded) |
Overall grade of acute GVHD at diagnosis | I - Rash on ≤ 50% of skin, no liver or gut involvement II - Rash on > 50% of skin, bilirubin 2-3 mg/dL, or diarrhea 500 – 1000 mL/day or persistent nausea or vomiting III - Bilirubin 3-15 mg/dL, or gut stage 2-4 diarrhea > 1000 mL/day or severe abdominal pain with or without ileus IV - Generalized erythroderma with bullous formation, or bilirubin >15 mg/dL Not applicable (acute GVHD present but cannot be graded) |
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| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Skin | Stage 0 – No rash, no rash attributable to acute GVHD Stage 1 – Maculopapular rash, < 25% of body surface Stage 2 – Maculopapular rash, 25–50% of body surface Stage 3 – Generalized erythroderma, > 50% of body surface Stage 4 – Generalized erythroderma with bullae formation and/or desquamation |
Skin | Stage 0 – No rash, no rash attributable to acute GVHD Stage 1 – Maculopapular rash, < 25% of body surface Stage 2 – Maculopapular rash, 25–50% of body surface Stage 3 – Generalized erythroderma, > 50% of body surface Stage 4 – Generalized erythroderma with bullae formation and/or desquamation |
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| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Lower intestinal tract (use mL/day for adult recipients and mL/kg/day for pediatric recipients) | Stage 0 – No diarrhea, no diarrhea attributable to acute GVHD / diarrhea < 500 mL/day (adult), or < 10 mL/kg/day (pediatric) Stage 1 – Diarrhea 500 - 1000 mL/day (adult), or 10 - 19.9 mL/kg/day (pediatric) Stage 2 – Diarrhea 1001 - 1500 mL/day (adult), or 20 - 30 mL/kg/day (pediatric) Stage 3 – Diarrhea > 1500 mL/day (adult), or > 30 mL/kg/day (pediatric) Stage 4 – Severe abdominal pain, with or without ileus, and/or grossly bloody stool |
Lower intestinal tract (use mL/day for adult recipients and mL/kg/day for pediatric recipients) | Stage 0 – No diarrhea, no diarrhea attributable to acute GVHD / diarrhea < 500 mL/day (adult), or < 10 mL/kg/day (pediatric) Stage 1 – Diarrhea 500 - 1000 mL/day (adult), or 10 - 19.9 mL/kg/day (pediatric) Stage 2 – Diarrhea 1001 - 1500 mL/day (adult), or 20 - 30 mL/kg/day (pediatric) Stage 3 – Diarrhea > 1500 mL/day (adult), or > 30 mL/kg/day (pediatric) Stage 4 – Severe abdominal pain, with or without ileus, and/or grossly bloody stool |
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| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Upper intestinal tract | Stage 0 – No persistent nausea or vomiting Stage 1 – Persistent nausea or vomiting |
Upper intestinal tract | Stage 0 – No persistent nausea or vomiting Stage 1 – Persistent nausea or vomiting |
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| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Liver | Stage 0 – No liver acute GVHD / bilirubin < 2.0 mg/dL (< 34 μmol/L) Stage 1 – Bilirubin 2.0–3.0 mg/dL (34–52 μmol/L) Stage 2 – Bilirubin 3.1–6.0 mg/dL (53–103 μmol/L) Stage 3 – Bilirubin 6.1–15.0 mg/dL (104–256 μmol/L) Stage 4 – Bilirubin > 15.0 mg/dL (> 256 μmol/L) |
Liver | Stage 0 – No liver acute GVHD / bilirubin < 2.0 mg/dL (< 34 μmol/L) Stage 1 – Bilirubin 2.0–3.0 mg/dL (34–52 μmol/L) Stage 2 – Bilirubin 3.1–6.0 mg/dL (53–103 μmol/L) Stage 3 – Bilirubin 6.1–15.0 mg/dL (104–256 μmol/L) Stage 4 – Bilirubin > 15.0 mg/dL (> 256 μmol/L) |
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| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Other site(s) involved with acute GVHD | No,Yes | Other site(s) involved with acute GVHD | No,Yes | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Specify other site(s): | open text | Specify other site(s): | open text | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Maximum overall grade of acute GVHD | I - Rash on ≤ 50% of skin, no liver or gut involvement II - Rash on > 50% of skin, bilirubin 2-3 mg/dL, or diarrhea 500 – 1000 mL/day or persistent nausea or vomiting III - Bilirubin 3-15 mg/dL, or gut stage 2-4 diarrhea > 1000 mL/day or severe abdominal pain with or without ileus IV - Generalized erythroderma with bullous formation, or bilirubin >15 mg/dL Not applicable (acute GVHD present but cannot be graded) |
Maximum overall grade of acute GVHD | I - Rash on ≤ 50% of skin, no liver or gut involvement II - Rash on > 50% of skin, bilirubin 2-3 mg/dL, or diarrhea 500 – 1000 mL/day or persistent nausea or vomiting III - Bilirubin 3-15 mg/dL, or gut stage 2-4 diarrhea > 1000 mL/day or severe abdominal pain with or without ileus IV - Generalized erythroderma with bullous formation, or bilirubin >15 mg/dL Not applicable (acute GVHD present but cannot be graded) |
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| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Date maximum overall grade of acute GVHD: | YYYY/MM/DD | Change/Clarification of Information Requested | First date maximum overall grade of acute GVHD: | YYYY/MM/DD | Capture data accurately |
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Skin | Stage 0 – No rash, no rash attributable to acute GVHD Stage 1 – Maculopapular rash, < 25% of body surface Stage 2 – Maculopapular rash, 25–50% of body surface Stage 3 – Generalized erythroderma, > 50% of body surface Stage 4 – Generalized erythroderma with bullae formation and/or desquamation |
Skin | Stage 0 – No rash, no rash attributable to acute GVHD Stage 1 – Maculopapular rash, < 25% of body surface Stage 2 – Maculopapular rash, 25–50% of body surface Stage 3 – Generalized erythroderma, > 50% of body surface Stage 4 – Generalized erythroderma with bullae formation and/or desquamation |
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| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Lower intestinal tract (use mL/day for adult recipients and mL/kg/day for pediatric recipients) | Stage 0 – No diarrhea, no diarrhea attributable to acute GVHD / diarrhea < 500 mL/day (adult), or < 10 mL/kg/day (pediatric) Stage 1 – Diarrhea 500 - 1000 mL/day (adult), or 10 - 19.9 mL/kg/day (pediatric) Stage 2 – Diarrhea 1001 - 1500 mL/day (adult), or 20 - 30 mL/kg/day (pediatric) Stage 3 – Diarrhea > 1500 mL/day (adult), or > 30 mL/kg/day (pediatric) Stage 4 – Severe abdominal pain, with or without ileus, and/or grossly bloody stool |
Lower intestinal tract (use mL/day for adult recipients and mL/kg/day for pediatric recipients) | Stage 0 – No diarrhea, no diarrhea attributable to acute GVHD / diarrhea < 500 mL/day (adult), or < 10 mL/kg/day (pediatric) Stage 1 – Diarrhea 500 - 1000 mL/day (adult), or 10 - 19.9 mL/kg/day (pediatric) Stage 2 – Diarrhea 1001 - 1500 mL/day (adult), or 20 - 30 mL/kg/day (pediatric) Stage 3 – Diarrhea > 1500 mL/day (adult), or > 30 mL/kg/day (pediatric) Stage 4 – Severe abdominal pain, with or without ileus, and/or grossly bloody stool |
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| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Upper intestinal tract | Stage 0 – No persistent nausea or vomiting Stage 1 – Persistent nausea or vomiting |
Upper intestinal tract | Stage 0 – No persistent nausea or vomiting Stage 1 – Persistent nausea or vomiting |
||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Liver | Stage 0 – No liver acute GVHD / bilirubin < 2.0 mg/dL (< 34 μmol/L) Stage 1 – Bilirubin 2.0–3.0 mg/dL (34–52 μmol/L) Stage 2 – Bilirubin 3.1–6.0 mg/dL (53–103 μmol/L) Stage 3 – Bilirubin 6.1–15.0 mg/dL (104–256 μmol/L) Stage 4 – Bilirubin > 15.0 mg/dL (> 256 μmol/L) |
Liver | Stage 0 – No liver acute GVHD / bilirubin < 2.0 mg/dL (< 34 μmol/L) Stage 1 – Bilirubin 2.0–3.0 mg/dL (34–52 μmol/L) Stage 2 – Bilirubin 3.1–6.0 mg/dL (53–103 μmol/L) Stage 3 – Bilirubin 6.1–15.0 mg/dL (104–256 μmol/L) Stage 4 – Bilirubin > 15.0 mg/dL (> 256 μmol/L) |
||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Other site(s) involved with acute GVHD | No,Yes | Other site(s) involved with acute GVHD | No,Yes | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Specify other site(s): | open text | Specify other site(s): | open text | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Did chronic GVHD develop since the date of last report? | No,Unknown,Yes | Did chronic GVHD develop since the date of last report? | No,Unknown,Yes | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Date of chronic GVHD diagnosis: | YYYY/MM/DD | Date of chronic GVHD diagnosis: | YYYY/MM/DD | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Date estimated | checked | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Did chronic GVHD persist since the date of last report? | No,Unknown,Yes | Did chronic GVHD persist since the date of last report? | No,Unknown,Yes | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Maximum grade of chronic GVHD (according to best clinical judgment) | Mild,Moderate,Severe,Unknown | Maximum grade of chronic GVHD (according to best clinical judgment) | Mild,Moderate,Severe,Unknown | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Date of maximum grade of chronic GVHD: | YYYY/MM/DD | Date of maximum grade of chronic GVHD: | YYYY/MM/DD | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Specify if chronic GVHD was limited or extensive | Extensive – One or more of the following: – Generalized skin involvement; or, – Liver histology showing chronic aggressive hepatitis, bridging necrosis or cirrhosis; or, – Involvement of eye: Schirmer’s test with < 5 mm wetting; or – Involvement of minor salivary glands or oral mucosa demonstrated on labial biopsy; or – Involvement of any other target organ, Limited - Localized skin involvement and/or liver dysfunction |
Specify if chronic GVHD was limited or extensive | Extensive – One or more of the following: – Generalized skin involvement; or, – Liver histology showing chronic aggressive hepatitis, bridging necrosis or cirrhosis; or, – Involvement of eye: Schirmer’s test with < 5 mm wetting; or – Involvement of minor salivary glands or oral mucosa demonstrated on labial biopsy; or – Involvement of any other target organ, Limited - Localized skin involvement and/or liver dysfunction |
||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Is the recipient still taking systemic steroids? (Do not report steroids for adrenal insufficiency, or steroid dose ≤10 mg/day for adults, <0.1 mg/kg/day for children) | No,Not Applicable,Unknown,Yes | Is the recipient still taking systemic steroids? (Do not report steroids for adrenal insufficiency, or steroid dose ≤10 mg/day for adults, <0.1 mg/kg/day for children) | No,Not Applicable,Unknown,Yes | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Is the recipient still taking (non-steroid) immunosuppressive agents (including PUVA) for GVHD? | No,Not Applicable,Unknown,Yes | Is the recipient still taking (non-steroid) immunosuppressive agents (including PUVA) for GVHD? | No,Not Applicable,Unknown,Yes | ||
| Post-Transplant Essential Data | no | yes | Was specific therapy used to prevent liver toxicity? | No,Yes | Was specific therapy used to prevent liver toxicity? | No,Yes | |||
| Post-Transplant Essential Data | no | yes | Specify therapy (check all that apply) | Defibrotide,N-acetylcysteine,Other therapy,Tissue plasminogen activator (TPA),Ursodiol | Change/Clarification of Response Options | Specify therapy (check all that apply) | Defibrotide,N-acetylcysteine,Other therapy,Tissue plasminogen activator (TPA),Ursodiol, Enoxaparin (Lovenox), Heparin | Be consistent with current clinical landscape, improve transplant outcome data | |
| Post-Transplant Essential Data | no | yes | Specify other therapy: | open text | Specify other therapy: | open text | |||
| Post-Transplant Essential Data | no | yes | Did veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) develop since the date of last report? | No,Yes | Did veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) develop since the date of last report? | No,Yes | |||
| Post-Transplant Essential Data | no | yes | Date of diagnosis: | YYYY/MM/DD | Date of diagnosis: | YYYY/MM/DD | |||
| Post-Transplant Essential Data | no | yes | Did the recipient develop COVID-19 (SARS-CoV-2) since the date of last report? | No,Yes | Did the recipient develop COVID-19 (SARS-CoV-2) since the date of last report? | No,Yes | |||
| Post-Transplant Essential Data | no | yes | Date of diagnosis: | YYYY/MM/DD | Date of diagnosis: | YYYY/MM/DD | |||
| Post-Transplant Essential Data | no | yes | Was a vaccine for COVID-19 (SARS-CoV-2) received? | No,Unknown,Yes | Was a vaccine for COVID-19 (SARS-CoV-2) received? | No,Unknown,Yes | |||
| Post-Transplant Essential Data | Covid-19 Vaccine | yes | yes | Specify vaccine brand | AstraZeneca,Johnson & Johnson,Moderna,Novavax,Other (specify),Pfizer-BioNTech | Specify vaccine brand | AstraZeneca,Johnson & Johnson,Moderna,Novavax,Other (specify),Pfizer-BioNTech | ||
| Post-Transplant Essential Data | Covid-19 Vaccine | yes | yes | Specify other type: | open text | Specify other type: | open text | ||
| Post-Transplant Essential Data | Covid-19 Vaccine | yes | yes | Select dose(s) received | Booster dose,First dose(with planned second dose) ,One dose(without planned second dose) ,Second dose,Third dose | Select dose(s) received | Booster dose,First dose(with planned second dose) ,One dose(without planned second dose) ,Second dose,Third dose | ||
| Post-Transplant Essential Data | Covid-19 Vaccine | yes | yes | Date received: | YYYY/MM/DD | Date received: | YYYY/MM/DD | ||
| Post-Transplant Essential Data | Covid-19 Vaccine | yes | yes | Date estimated | checked | Date estimated | checked | ||
| Post-Transplant Essential Data | no | yes | Did a new malignancy, myelodysplastic, myeloproliferative, or lymphoproliferative disease / disorder occur that is different from the disease / disorder for which the HCT or cellular therapy was performed? | No,Yes | Change/Clarification of Response Options | Did a new malignancy, myelodysplastic, myeloproliferative, or lymphoproliferative disease / disorder occur that is different from the disease / disorder for which the HCT or cellular therapy was performed? | No,Yes (Also complete Subsequent Neoplasms) , previosly reported | Capture additional relevent disease information | |
| Post-Transplant Essential Data | Allogenic Recipients of Cord Blood units, Beta Thalassemia, and/or Sickle Cell Disease | yes | yes | Were chimerism studies performed since the date of last report? | no,yes | Were chimerism studies performed since the date of last report? | no,yes | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Was documentation submitted to the CIBMTR? (e.g. chimerism laboratory reports) | No,Yes | Was documentation submitted to the CIBMTR? (e.g. chimerism laboratory reports) | No,Yes | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Were chimerism studies assessed for more than one donor / multiple donors? | No,Yes | Were chimerism studies assessed for more than one donor / multiple donors? | No,Yes | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Global Registration Identifier for Donors (GRID) | open text | Global Registration Identifier for Donors (GRID) | open text | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | NMDP cord blood unit ID: | open text | NMDP cord blood unit ID: | open text | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Registry donor ID: | open text | Registry donor ID: | open text | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Non-NMDP cord blood unit ID: | open text | Non-NMDP cord blood unit ID: | open text | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Date of birth: | YYYY/MM/DD | Change/Clarification of Information Requested | Donor Date of birth: | YYYY/MM/DD | Capture data accurately |
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Age: | MM __ __ (if less than 1 year); YY __ __ __ | Age: | MM __ __ (if less than 1 year); YY __ __ __ | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Sex | female,male | Change/Clarification of Information Requested | Donor Sex | female,male | Capture data accurately |
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Date sample collected: | YYYY/MM/DD | Date sample collected: | YYYY/MM/DD | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Method | Fluorescent in situ hybridization (FISH) for XX/XY,Karyotyping for XX/XY,Other,Restriction fragment-length polymorphisms (RFLP),VNTR or STR, micro or mini satellite | Change/Clarification of Response Options | Method | PCR(includes quantitative, real time, and fluorescent multiplex), Fluorescent in situ hybridization (FISH) for XX/XY,Karyotyping for XX/XY,Other,Restriction fragment-length polymorphisms (RFLP),VNTR or STR, micro or mini satellite | Examples added or typographical errors corrected for clarification |
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Specify: | open text | Specify: | open text | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Cell source | Bone marrow,Peripheral blood | Cell source | Bone marrow,Peripheral blood | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Cell type | B-cells,Granulocytes,Hematopoietic progenitor cells,NK cells,Other,Red blood cells,T-cells,Total mononuclear cells,Unsorted / whole | Cell type | B-cells,Granulocytes,Hematopoietic progenitor cells,NK cells,Other,Red blood cells,T-cells,Total mononuclear cells,Unsorted / whole | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Specify: | open text | Specify: | open text | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Total cells examined: | open text | Total cells examined: | open text | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Number of donor cells: | open text | Number of donor cells: | open text | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Were donor cells detected? | No,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Percent donor cells: | __ __ __ % | Percent donor cells: | __ __ __ % | ||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Compared to the disease status prior to the preparative regimen, what was the best response to HCT since the date of the last report? | Continued complete remission (CCR),Complete remission (CR),Not in complete remission,Not evaluated | Compared to the disease status prior to the preparative regimen, what was the best response to HCT since the date of the last report? | Continued complete remission (CCR),Complete remission (CR),Not in complete remission,Not evaluated | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Specify disease status if not in complete remission | Disease detected,No disease detected but incomplete evaluation to establish CR | Specify disease status if not in complete remission | Disease detected,No disease detected but incomplete evaluation to establish CR | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was the date of best response previously reported? | no,yes | Was the date of best response previously reported? | no,yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was the disease status assessed by molecular testing? | No,Not Applicable,Yes | Was the disease status assessed by molecular testing? | No,Not Applicable,Yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was disease detected? | no,yes | Was disease detected? | no,yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was the disease status assessed via flow cytometry? | No,Not Applicable,Yes | Was the disease status assessed via flow cytometry? | No,Not Applicable,Yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was disease detected? | no,yes | Was disease detected? | no,yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was the disease status assessed by cytogenetic testing? (karyotyping or FISH) | No,Not Applicable,Yes | Was the disease status assessed by cytogenetic testing? (karyotyping or FISH) | No,Not Applicable,Yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was the disease status assessed via FISH? | No,Not Applicable,Yes | Was the disease status assessed via FISH? | No,Not Applicable,Yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was disease detected? | no,yes | Was disease detected? | no,yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was the disease status assessed via karyotyping? | No,Not Applicable,Yes | Was the disease status assessed via karyotyping? | No,Not Applicable,Yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was disease detected? | no,yes | Was disease detected? | no,yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was the disease status assessed by radiological assessment? (e.g. PET, MRI, CT) | No,Not Applicable,Yes | Was the disease status assessed by radiological assessment? (e.g. PET, MRI, CT) | No,Not Applicable,Yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was disease detected? | no,yes | Was disease detected? | no,yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was the disease status assessed by clinical / hematologic assessment? | no,yes | Was the disease status assessed by clinical / hematologic assessment? | no,yes | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Date assessed: | YYYY/MM/DD | Date assessed: | YYYY/MM/DD | |||
| Disease Assessment at the Time of Best Response to HCT | no | yes | Was disease detected? | no,yes | Was disease detected? | no,yes | |||
| Post-HCT Therapy | no | yes | Was therapy given since the date of the last report for reasons other than relapse, persistent, or progressive disease? (Include any maintenance and consolidation therapy.) | no,yes | Was therapy given since the date of the last report for reasons other than relapse, persistent, or progressive disease? (Include any maintenance and consolidation therapy.) | no,yes | |||
| Post-HCT Therapy | no | yes | Specify therapy (check all that apply) | Blinded randomized trial,Cellular therapy,Other therapy,Radiation,Systemic therapy | Specify therapy (check all that apply) | Blinded randomized trial,Cellular therapy,Other therapy,Radiation,Systemic therapy | |||
| Post-HCT Therapy | no | yes | Specify systemic therapy (check all that apply) | Alemtuzumab,Azacytidine,Blinatumomab,Bortezomib,Bosutinib,Carfilzomib,Chemotherapy,Dasatinib,Decitabine,Gemtuzumab,Gilteritinib,Ibrutinib,Imatinib mesylate,Ixazomib,Lenalidomide,Lestaurtinib,Midostaurin,Nilotinib,Nivolumab,Other systemic therapy,Pembrolizumab,Pomalidomide,Quizartinib,Rituximab,Sorafenib,Sunitinib,Thalidomide | Change/Clarification of Response Options | Specify systemic therapy (check all that apply) | Alemtuzumab,Azacytidine,Blinatumomab,Bortezomib,Bosutinib,Carfilzomib,Chemotherapy,Dasatinib,Decitabine,Gemtuzumab,Gilteritinib,Ibrutinib,Imatinib mesylate,Ixazomib,Lenalidomide,Lestaurtinib,Midostaurin,Nilotinib,Nivolumab,Other systemic therapy,Pembrolizumab,Pomalidomide,Quizartinib,Rituximab,Sorafenib,Sunitinib,Thalidomide, Brentuximab vendotin, Daratumumab (Darzalex) | Be consistent with current clinical landscape, improve transplant outcome data | |
| Post-HCT Therapy | no | yes | Specify other systemic therapy: | open text | Specify other systemic therapy: | open text | |||
| Post-HCT Therapy | no | yes | Specify other therapy: | open text | Specify other therapy: | open text | |||
| Post-HCT Therapy | no | yes | Addition of Information Requested |
Did a fecal microbiota transplant (FMT) occur since the date of last report? | No, Yes | Be consistent with current clinical landscape, improve transplant outcome data | |||
| Post-HCT Therapy | no | yes | Addition of Information Requested |
Date of FMT | DD/MM/YY | Be consistent with current clinical landscape, improve transplant outcome data | |||
| Post-HCT Therapy | no | yes | Addition of Information Requested |
Specify the indication for the FMT | Graft versus host disease (GVHD), Clostridium difficle, Other | Be consistent with current clinical landscape, improve transplant outcome data | |||
| Post-HCT Therapy | no | yes | Addition of Information Requested |
Specify other indication: | open text | Be consistent with current clinical landscape, improve transplant outcome data | |||
| Relapse or Progression Post-HCT | no | yes | Did the recipient experience a clinical/hematologic relapse or progression post-HCT? | No,Yes | Did the recipient experience a clinical/hematologic relapse or progression post-HCT? | No,Yes | |||
| Relapse or Progression Post-HCT | no | yes | Was the date of the first clinical / hematologic relapse or progression previously reported? | No,Yes (only valid >day 100) | Was the date of the first clinical / hematologic relapse or progression previously reported? | No,Yes (only valid >day 100) | |||
| Relapse or Progression Post-HCT | no | yes | Date first seen: | YYYY/MM/DD | Date first seen: | YYYY/MM/DD | |||
| Relapse or Progression Post-HCT | no | yes | Was intervention given for relapsed, persistent or progressive disease since the date of last report? | No,Yes | Was intervention given for relapsed, persistent or progressive disease since the date of last report? | No,Yes | |||
| Relapse or Progression Post-HCT | no | yes | Specify reason for which intervention was given | Persistent disease,Relapsed / progressive disease | Specify reason for which intervention was given | Persistent disease,Relapsed / progressive disease | |||
| Relapse or Progression Post-HCT | no | yes | Specify the method(s) of detection for which intervention was given (check all that apply) | Clinical and/or hematologic analysis,Cytogenetic Analysis,Disease specific molecular marker,Flow Cytometry,Radiological | Specify the method(s) of detection for which intervention was given (check all that apply) | Clinical and/or hematologic analysis,Cytogenetic Analysis,Disease specific molecular marker,Flow Cytometry,Radiological | |||
| Relapse or Progression Post-HCT | no | yes | Date intervention started: | YYYY/MM/DD | Date intervention started: | YYYY/MM/DD | |||
| Relapse or Progression Post-HCT | no | yes | Specify therapy (check all that apply) | Blinded randomized trial,Cellular therapy,Other therapy,Radiation,Systemic therapy | Specify therapy (check all that apply) | Blinded randomized trial,Cellular therapy,Other therapy,Radiation,Systemic therapy | |||
| Relapse or Progression Post-HCT | no | yes | Specify systemic therapy (check all that apply) | Alemtuzumab,Azacytidine,Blinatumomab,Bortezomib,Bosutinib,Carfilzomib,Chemotherapy,Dasatinib,Decitabine,Gemtuzumab,Gilteritinib,Ibrutinib,Imatinib mesylate,Ixazomib,Lenalidomide,Lestaurtinib,Midostaurin,Nilotinib,Nivolumab,Other systemic therapy,Pembrolizumab,Pomalidomide,Quizartinib,Rituximab,Sorafenib,Sunitinib,Thalidomide | Change/Clarification of Response Options | Specify systemic therapy (check all that apply) | Alemtuzumab,Azacytidine,Blinatumomab,Bortezomib,Bosutinib,Carfilzomib,Chemotherapy,Dasatinib,Decitabine,Gemtuzumab,Gilteritinib,Ibrutinib,Imatinib mesylate,Ixazomib,Lenalidomide,Lestaurtinib,Midostaurin,Nilotinib,Nivolumab,Other systemic therapy,Pembrolizumab,Pomalidomide,Quizartinib,Rituximab,Sorafenib,Sunitinib,Thalidomide, Daratumumb (Darzalex), Venetoclax | Be consistent with current clinical landscape, improve transplant outcome data | |
| Relapse or Progression Post-HCT | no | yes | Specify other systemic therapy: | open text | Specify other systemic therapy: | open text | |||
| Relapse or Progression Post-HCT | no | yes | Specify other therapy: | open text | Specify other therapy: | open text | |||
| Current Disease Status | no | yes | What is the current disease status? | Complete remission (CR),Not in complete remission,Not evaluated | What is the current disease status? | Complete remission (CR),Not in complete remission,Not evaluated | |||
| Current Disease Status | no | yes | Specify disease status if not in complete remission | Disease detected,No disease detected but incomplete evaluation to establish CR | Specify disease status if not in complete remission | Disease detected,No disease detected but incomplete evaluation to establish CR | |||
| Current Disease Status | no | yes | Date of most recent disease assessment | Known,Unknown | Deletion of Information Requested | Reduce redundancy in data capture | |||
| Current Disease Status | no | yes | Date of most recent disease assessment: | YYYY/MM/DD | Change/Clarification of Information Requested | Date of most recent disease assessment Date of assesment of current disease status | YYYY/MM/DD | Reduce redundancy in data capture | |
| Recipient Death Data | Recipient Death | yes | no | Addition of Information Requested |
Date of death: | YYYY/MM/DD | Reduce redundancy in data capture | ||
| Recipient Death Data | Recipient Death | yes | no | Addition of Information Requested |
Date estimated | checked | Reduce redundancy in data capture | ||
| Recipient Death Data | Recipient Death | yes | no | Addition of Information Requested |
Was cause of death confirmed by autopsy? | Autopsy pending,No,Unknown,Yes | Reduce redundancy in data capture | ||
| Recipient Death Data | Recipient Death | yes | no | Addition of Information Requested |
Was documentation submitted to the CIBMTR? | No,Yes | Reduce redundancy in data capture | ||
| Recipient Death Data | Recipient Death | yes | no | Primary cause of death | Accidental death,Acute GVHD,Adult respiratory distress syndrome (ARDS) (other than IPS),Bacterial infection,Cardiac failure,Chronic GVHD,Central nervous system (CNS) failure,COVID-19 (SARS-CoV-2),Cytokine release syndrome,Diffuse alveolar damage (without hemorrhage), Disseminated intravascular coagulation (DIC),Fungal infection, Gastrointestinal (GI) failure (not liver),Graft rejection or failure, Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)),Idiopathic pneumonia syndrome (IPS), Liver failure (not VOD),Multiple organ failure,New malignancy,Infection, organism not identified,Other cause, Other infection,Other organ failure,Other pulmonary syndrome (excluding pulmonary hemorrhage),Other vascular,Prior malignancy,Protozoal infection, Pulmonary failure,Recurrence / persistence / progression of disease,Renal failure,Suicide,Thromboembolic, Pneumonitis due to Cytomegalovirus (CMV),Viral infection,Pneumonitis due to other virus,Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) | Change/Clarification of Response Options | Primary cause of death | Accidental death,Acute GVHD,Adult respiratory distress syndrome (ARDS) (other than IPS),Bacterial infection,Cardiac failure,Chronic GVHD,Central nervous system (CNS) failure,COVID-19 (SARS-CoV-2),Cytokine release syndrome,Diffuse alveolar damage (without hemorrhage),Diffuse alveolar hemorrhage (DAH),Disseminated intravascular coagulation (DIC),Fungal infection,Gastrointestinal hemorrhage,Gastrointestinal (GI) failure (not liver),Graft rejection or failure,Hemorrhagic cystitis,Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)),Idiopathic pneumonia syndrome (IPS),Intracranial hemorrhage,Liver failure (not VOD),Multiple organ failure,New malignancy,Infection, organism not identified,Other cause,Other hemorrhage neurotoxicity (ICANS), Other infection,Other organ failure,Other pulmonary syndrome (excluding pulmonary hemorrhage),Other vascular,Prior malignancy,Protozoal infection,Pulmonary hemorrhage,Pulmonary failure,Recurrence / persistence / progression of disease,Renal failure,Suicide,Thromboembolic, Tumor lysis syndrome, Pneumonitis due to Cytomegalovirus (CMV),Viral infection,Pneumonitis due to other virus,Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) | Be consistent with current clinical landscape, improve transplant outcome data |
| Recipient Death Data | Recipient Death | yes | no | Specify: | open text | Specify: | open text | ||
| Recipient Death Data | Recipient Death | yes | no | Contributing cause of death | Accidental death,Acute GVHD,Adult respiratory distress syndrome (ARDS) (other than IPS),Bacterial infection,Cardiac failure,Chronic GVHD,Central nervous system (CNS) failure,COVID-19 (SARS-CoV-2),Cytokine release syndrome,Diffuse alveolar damage (without hemorrhage), Disseminated intravascular coagulation (DIC),Fungal infection, Gastrointestinal (GI) failure (not liver),Graft rejection or failure, Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)),Idiopathic pneumonia syndrome (IPS), Liver failure (not VOD),Multiple organ failure,New malignancy,Infection, organism not identified,Other cause, Other infection,Other organ failure,Other pulmonary syndrome (excluding pulmonary hemorrhage),Other vascular,Prior malignancy,Protozoal infection, Pulmonary failure,Recurrence / persistence / progression of disease,Renal failure,Suicide,Thromboembolic, Pneumonitis due to Cytomegalovirus (CMV),Viral infection,Pneumonitis due to other virus,Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) | Change/Clarification of Response Options | Contributing cause of death | Accidental death,Acute GVHD,Adult respiratory distress syndrome (ARDS) (other than IPS),Bacterial infection,Cardiac failure,Chronic GVHD,Central nervous system (CNS) failure,COVID-19 (SARS-CoV-2),Cytokine release syndrome,Diffuse alveolar damage (without hemorrhage),Diffuse alveolar hemorrhage (DAH),Disseminated intravascular coagulation (DIC),Fungal infection,Gastrointestinal hemorrhage,Gastrointestinal (GI) failure (not liver),Graft rejection or failure,Hemorrhagic cystitis,Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)),Idiopathic pneumonia syndrome (IPS),Intracranial hemorrhage,Liver failure (not VOD),Multiple organ failure,New malignancy,Infection, organism not identified,Other cause,Other hemorrhage neurotoxicity (ICANS), Other infection,Other organ failure,Other pulmonary syndrome (excluding pulmonary hemorrhage),Other vascular,Prior malignancy,Protozoal infection,Pulmonary hemorrhage,Pulmonary failure,Recurrence / persistence / progression of disease,Renal failure,Suicide,Thromboembolic, Tumor lysis syndrome, Pneumonitis due to Cytomegalovirus (CMV),Viral infection,Pneumonitis due to other virus,Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) | Be consistent with current clinical landscape, improve transplant outcome data |
| Recipient Death Data | Recipient Death | yes | no | Specify: | open text | Specify: | open text | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Specify the new malignancy | Hematologic Malignancy: Acute myeloid leukemia (AML / ANLL), Other leukemia, Myelodysplastic syndrome (MDS), Myeloproliferative neoplasm (MPN), Overlapping myelodysplasia / myeloproliferative neoplasm (MDS / MPN), Hodgkin lymphoma, Non-Hodgkin lymphoma, Clonal cytogenetic abnormality without leukemia or MDS, Uncontrolled proliferation of donor cells without malignant transformation Solid Tumors: Oropharyngeal cancer (e.g. tongue, mouth, throat), Gastrointestinal malignancy (e.g. esophagus, stomach, small intestine, colon, rectum, anus, liver, pancreas), Lung cancer, Melanoma, Squamous cell skin malignancy, Basal cell skin malignancy, Breast cancer, Genitourinary malignancy (e.g. kidney, bladder, cervix, uterus, ovary, prostate, testis), Central nervous system (CNS) malignancy (e.g. meningioma, glioma), Thyroid cancer |
Change/Clarification of Response Options | Specify the new malignancy | Hematologic Malignancy: Acute myeloid leukemia (AML / ANLL), Acute lymphoblastic leukemia (ALL), Other leukemia, Myelodysplastic syndrome (MDS), Myeloproliferative neoplasm (MPN), Overlapping myelodysplasia / myeloproliferative neoplasm (MDS / MPN), Hodgkin lymphoma, Non-Hodgkin lymphoma, Multiple myeloma / plasma cell neoplasms, Clonal cytogenetic abnormality without leukemia or MDS, Uncontrolled proliferation of donor cells without malignant transformation. Solid Tumors: Bone sarcoma (regardless of site), Soft tissue sarcoma (regardless of site), Oropharyngeal cancer (e.g. tongue, mouth, throat), Gastrointestinal malignancy (e.g. esophagus, stomach, small intestine, colon, rectum, anus, liver, pancreas), Lung cancer, Melanoma, Squamous cell skin malignancy, Basal cell skin malignancy, Breast cancer, Genitourinary malignancy (e.g. kidney, bladder, cervix, uterus, ovary, prostate, testis), Central nervous system (CNS) malignancy (e.g. meningioma, glioma), Thyroid cancer |
Be consistent with current clinical landscape, improve transplant outcome data |
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was post-transplant lymphoproliferative disorder (PTLD) diagnosed? | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify type of PTLD | Monomorphic,Polymorphic,Unknown | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify oropharyngeal cancer | Mouth,Throat,Tongue, Other oropharyngeal cancer | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify gastrointestinal malignancy | Anus,Colon,Esophagus,Liver ,Pancreas,Rectum,Small intestine (DUODENUM, JEJUNUM, ILEUM),Stomach, Other gastrointestinall cancer | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify genitourinary malignancy | Bladder,Cervix,Kidney,Ovary,Prostate,Testicle,Uterus, Other genitourary malignancy | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify CNS malignancy | Glioma,Meningioma,Other CNS malignancy | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Specify other new malignancy: | open text | Specify other new malignancy: | open text | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Date of diagnosis: | YYYY/MM/DD | Date of diagnosis: | YYYY/MM/DD | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Was documentation submitted to the CIBMTR? | No,Yes | Was documentation submitted to the CIBMTR? | No,Yes | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Was the new malignancy donor / cell product derived? | No,Not Done,Yes | Was the new malignancy donor / cell product derived? | No,Not Done,Yes | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Was documentation submitted to the CIBMTR? | no,yes | Was documentation submitted to the CIBMTR? | no,yes | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was PTLD confirmed by biopsy? | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Was the pathology of the tumor EBV positive? | no,yes | Was the pathology of the tumor EBV positive? | no,yes | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was documentation submitted to the CIBMTR? (e.g. pathology report) | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was there EBV reactivation in the blood? | No,Not Done,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
How was EBV reactivation diagnosed? | Other method,Qualitative PCR of blood,Quantitative PCR of blood | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify other method: | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Quantitative EBV viral load of blood: At diagnosis | _____ copies/ml | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was a quantitative PCR of blood performed again after diagnosis? | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Highest EBV viral load of blood: | ______copies/ml | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was there lymphomatous involvement? | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify sites of PTLD involvement (check all that apply) | Bone marrow,Central nervous system (brain or cerebrospinal fluid),Liver,Lung,Lymph node(s),Other,Spleen | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify other site: | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | no | yes | First Name (person completing form): | open text | First Name (person completing form): | open text | |||
| Subsequent Neoplasms | no | yes | Last Name: | open text | Last Name: | open text | |||
| Subsequent Neoplasms | no | yes | E-mail address: | open text | E-mail address: | open text | |||
| Subsequent Neoplasms | no | yes | Date: | YYYY/MM/DD | Date: | YYYY/MM/DD | |||
Sheet 4: Header Definitions
|
|
Information Collection Domains |
| Indicates the category of information collection by time period that corresponds to the burden table. For each of the following Domains, there is a corresponding Tab. 1- Pre-Transplant Information Collection 2- Transplant Procedure and Product Information 3- Post-Transplant Periodic Information Collection Below are the defintions for each column heading. |
|
| Column Header Title | Column Header Title Definitions |
| Information Collection Domain Sub-Type | Identifies a grouping of information collection within an Information Collection Domain. These information collection domain sub types roughly correspond to section/domain headers currently found on CIBMTR data collection instruments. |
| Information Collection Domain Additional Sub Domain | Additional Sub Domain set recipeint, donor, infusion type or product criteria that must be met for an information collection element to be required |
| Response required if Additional Sub Domain applies | Response options are "yes" or "no". If the criteria noted in Additional sub domain applies, the information collection data element will be applicable and information collection data element responses supplied. Always "yes" when an additional sub domain is present. |
| Information Collection may be requested at multiple times | Response options are "yes" or "no". Some information may be collected at "multiple" time points or in multiple iterations. A multiple request may occur with a new or duplicate event, new infusion, changes in treatment or outcomes follow up. For example: product analyses at multple timepoints, chimerism analyses on multple dates, subsequent neoplasms, co-morbidities, covid infection, Disease Status, Post Transplant Therapy, GVHD, labs and pathology (collected at diagnosis, between diagnosis and infusion, at infusion and during followup) |
| Current Information Collection Data Element (if applicable) | Depicts the information collection data element currently being requested. |
| Current Information Collection Data Element Response Option(s) | Depicts the information collection data element response options currently being requested. |
| Information Collection update: | Notes the type of update. If Blank, there was no change. |
| options: | |
| Addition of Information Requested | |
| Deletion of Information Requested | |
| Deletion of Information: Merged to Check all that Apply | |
| Change/Clarification of Information Requested | |
| Change/Clarification of Response Options | |
| Change/Clarification of Information Requested and Response Options | |
| Proposed Information Collection Data Element (if applicable) | Depicts the changes to the information collection data element requested in red line format. Rows containing changes are highlighted in Yellow |
| Proposed Information Collection Data Element Response Option(s) | Depicts the changes to the information collection data element response options in red line format. Rows containing changes are highlighted in yellow. |
| Rationale for Information Collection Update | The following options identify the change summary: |
| options: | |
| Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |
| Be consistent with current clinical landscape, improve transplant outcome data | |
| Capture data accurately | |
| Examples added or typographical errors corrected for clarification | |
| Covid-19 Impact | |
| Capture additional relevent disease information |
Sheet 5: Change Summary
|
|
Change Summary of all Information Collection Data Element and Response Changes | ||||||||
| Information Collection Domain Sub-Type | Information Collection Domain Additional Sub Domain | Response required if Additional Sub Domain applies | Information Collection may be requested multiple times | Current Information Collection Data Element (if applicable) | Current Information Collection Data Element Response Option(s) | Information Collection update: | Proposed Information Collection Data Element (if applicable) | Proposed Information Collection Data Element Response Option(s) | Rationale for Information Collection Update |
| Pre-Transplant Essential Data | Clinical Trial Participants | yes | no | Study Sponsor | BMT CTN,COG,Other,PIDTC,RCI BMT,USIDNET | Change/Clarification of Response Options | Study Sponsor | BMT CTN,COG,Other,PIDTC,RCI BMT,USIDNET, PedAL | Be consistent with current clinical landscape, improve transplant outcome data |
| Pre-Transplant Essential Data | Allogeneic Donors | yes | yes | Non-NMDP unrelated donor ID: | open text | Change/Clarification of Information Requested | Non-NMDP unrelated donor ID:Registry donor ID: | open text | Capture data accurately |
| Pre-Transplant Essential Data | Autologous Transplant | yes | yes | 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, Anti-CD20 (rituximab, Rituxan), Other agent | Change/Clarification of Response Options | What agents were used to mobilize the autologous recipient for this HCT? (check all that apply) | G-CSF (TBO-filgrastim, filgrastim, Granix, Neupogen) ,GM-CSF (sargramostim, Leukine), Pegylated G-CSF (pegfilgrastim, Neulasta), Plerixafor (Mozobil), Combined with chemotherapy, Anti-CD20 (rituximab, Rituxan), Other agent | Be consistent with current clinical landscape, improve transplant outcome data |
| Pre-Transplant Essential Data | Was mechanical ventilation used for COVID-19 (SARS-CoV-2) infection? | No,Yes | Change/Clarification of Information Requested | Was mechanical ventilation used given for COVID-19 (SARS-CoV-2) infection? | No,Yes | Examples added or typographical errors corrected for clarification | |||
| Pre-Transplant Essential Data | Comorbid Conditions | Yes | no | 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 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 cell) Other hematologic malignancy Other solid tumor |
Change/Clarification of Response Options | 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 Acute myeloid leukemia Chronic myeloid leukemia Acute lymphoblastic leukemia Chronic lymphoblastic 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 cell) Other hematologic malignancy Other solid tumor |
Be consistent with current clinical landscape, improve transplant outcome data |
| Pre-Transplant Essential Data | Comorbid Conditions | Yes | no | Specify other skin malignancy: (prior) | open text | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Pre-Transplant Essential Data | no | no | Height at initiation of pre-HCT preparative regimen: | ___ ___ ___ inches ___ ___ ___ cms |
Change/Clarification of Response Options | Height at initiation of pre-HCT preparative regimen: | ___ ___ ___ inches ___ ___ ___ cms |
Capture data accurately | |
| Pre-HCT Preparative Regimen | no | no | Drug (drop down list) | Bendamustine,Busulfan,Carboplatin,Carmustine,Clofarabine,Cyclophosphamide,Cytarabine,Etoposide,Fludarabine,Gemcitabine,Ibritumomab tiuxetan,Ifosfamide,Lomustine,Melphalan,Methylprednisolone,Other,Pentostatin,Propylene glycol-free melphalan,Rituximab,Thiotepa,Tositumomab,Treosulfan | Change/Clarification of Response Options | Drug (drop down list) | Bendamustine,Busulfan,Carboplatin,Carmustine,Clofarabine,Cyclophosphamide,Cytarabine,Etoposide,Fludarabine,Gemcitabine,Ibritumomab tiuxetan,Ifosfamide,Lomustine,Melphalan,Methylprednisolone,Other,Pentostatin,Propylene glycol-free melphalan,Rituximab,Thiotepa,Tositumomab,Treosulfan, Azathioprine, Bortezomib, Cisplatin, Hydroxyurea, and Vincristine. | Be consistent with current clinical landscape, improve transplant outcome data | |
| Additional Drugs Given In the Peri-Transplant Period | no | no | ALG, ALS, ATG, ATS | no,yes | Change/Clarification of Information Requested and Response Option | ALG, ALS, ATG, ATS, Alemtuzumab, Defibrotide, KGF, Ursodiol | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | ||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Alemtuzumab (Campath) | no,yes | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Defibrotide | No,Yes | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | KGF | No,Yes | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |||
| Additional Drugs Given In the Peri-Transplant Period | no | no | Ursodiol | No,Yes | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Was the HCT impacted for a reason related to the COVID-19 (SARS-CoV-2) pandemic? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Is the HCT date different than the originally intended HCT date? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Original Date of HCT | YYYY/MM/DD | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Date estimated | checked | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Is the donor different than the originally intended donor? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Specify the originally intended donor | unrelated donor, syngeneic (monozygotic twin) , HLA-idential sibling (may include non-monozygotic twin) , HLA-matched other relative (does NOT include a haplo-identical donor), HLA-mismatched relative | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Is the product type (bone marrow, PBSC, cord blood unit) different than the originally intended product type? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Specify the originally intended product type | bone marrow,Other product,PBSC, cord blood unit | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Specify other product type | open text | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Was the current product thawed from a cryopreserved state prior to infusion? | no,yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Did the preparative regimen change from the original plan? | no, yes | Covid-19 Impact | |||
| Covid-19 Impact | no | no | Addition of Information Requested |
Did the GVHD prophylaxis change from the original plan? | no,yes | Covid-19 Impact | |||
| Disease Classification | no | no | What was the primary disease for which the HCT / cellular therapy was performed? | Autoimmune diseases,Acute lymphoblastic leukemia (ALL),Acute myelogenous leukemia (AML or ANLL),Chronic myelogenous leukemia (CML),Hemoglobinopathies,Histiocytic disorders,Hodgkin lymphoma,Inherited Bone Marrow Failure Syndromes(If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.)– ,Disorders of the immune system,Inherited disorders of metabolism,Inherited abnormalities of platelets,Myelodysplastic syndrome (MDS) (If recipient has transformed to AML, indicate AML as the primary disease.),Myeloproliferative neoplasms (MPN)(If recipient has transformed to AML, indicate AML as the primary disease.),Non-Hodgkin lymphoma,Acute leukemia of ambiguous lineage and other myeloid neoplasms,Other disease,Other leukemia (includes CLL),Multiple myeloma / plasma cell disorder (PCD),Paroxysmal nocturnal hemoglobinuria (PNH),Recessive dystrophic epidermolysis bullosa,Aplastic Anemia(If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.) ,Solid tumors,Tolerance induction associated with solid organ transplant | Change/Clarification of Response Options | What was the primary disease for which the HCT / cellular therapy was performed? | Autoimmune diseases,Acute lymphoblastic leukemia (ALL),Acute myelogenous myeloid leukemia (AML or ANLL),Chronic myelogenous leukemia (CML),Hemoglobinopathies,Histiocytic disorders,Hodgkin lymphoma,Inherited Bone Marrow Failure Syndromes(If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.)– ,Disorders of the immune system,Inherited disorders of metabolism,Inherited abnormalities of platelets,Myelodysplastic syndrome (MDS) (If recipient has transformed to AML, indicate AML as the primary disease.),Myeloproliferative neoplasms (MPN)(If recipient has transformed to AML, indicate AML as the primary disease.),Non-Hodgkin lymphoma,Acute leukemia of ambiguous lineage and other myeloid neoplasms,Other disease,Other leukemia (includes CLL),Multiple myeloma / plasma cell disorder (PCD),Paroxysmal nocturnal hemoglobinuria (PNH),Recessive dystrophic epidermolysis bullosa,Aplastic Anemia(If the recipient developed MDS or AML, indicate MDS or AML as the primary disease.) ,Solid tumors,Tolerance induction associated with solid organ transplant | Capture data accurately | |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis) | no,Unknown,yes | Change/Clarification of Information Requested | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis or relapse) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were tests for molecular markers performed? (at diagnosis) | no,Unknown,yes | Change/Clarification of Information Requested | Were tests for molecular markers performed? (at diagnosis or relapse) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify CEBPA mutation | Biallelic (homozygous),Monoallelic (heterozygous),Unknown | Change/Clarification of Response Options | Specify CEBPA mutation | Biallelic (double mutant),Monoallelic (single mutant),Unknown | Capture data accurately |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation) | no,Unknown,yes | Change/Clarification of Information Requested | Were cytogenetics tested (karyotyping or FISH)? (between diagnosis or relapse and last evaluation) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis and last evaluation) | no,Unknown,yes | Change/Clarification of Information Requested | Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis or relapse and last evaluation) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify CEBPA mutation | Biallelic (homozygous),Monoallelic (heterozygous),Unknown | Change/Clarification of Response Options | Specify CEBPA mutation | Biallelic (double mutant),Monoallelic (single mutant),Unknown | Capture data accurately |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | yes | Specify CEBPA mutation | Biallelic (homozygous),Monoallelic (heterozygous),Unknown | Change/Clarification of Response Options | Specify CEBPA mutation | Biallelic (double mutant),Monoallelic (single mutant),Unknown | Capture data accurately |
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Was the recipient in remission by flow cytometry? | Not applicable,No,Unknown,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Specify method(s) that was used to assess measurable residual disease status (check all that apply) | FISH, Karyotyping, Flow Cytometry, PCR, NGS, Not assessed | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by FISH? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by karyotyping assay? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Which leukemia phenotype was used for detection (check all the apply) | original leukemia immunophenotype, aberrant phenotype | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
What is the lower limit of detection (for the original leukemia immunophenotype) | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
What is the lower limit of detection (for the aberrant phenotype) | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by flow cytometry? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by PCR? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Myelogenous Leukemia (AML) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by NGS? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis) | no,Unknown,yes | Change/Clarification of Information Requested | Were cytogenetics tested (karyotyping or FISH)? (at diagnosis or relapse) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were tests for molecular markers performed? (at diagnosis) | no,Unknown,yes | Change/Clarification of Information Requested | Were tests for molecular markers performed? (at diagnosis or relapse) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were cytogenetics tested (karyotyping or FISH)? (between diagnosis and last evaluation) | no,Unknown,yes | Change/Clarification of Information Requested | Were cytogenetics tested (karyotyping or FISH)? (between diagnosis or at relapse and last evaluation) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | yes | Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis and last evaluation) | no,Unknown,yes | Change/Clarification of Information Requested | Were tests for molecular markers performed? (e.g. PCR, NGS) (between diagnosis or relapse and last evaluation) | no,Unknown,yes | Reduce redundancy in data capture |
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Was the recipient in remission by flow cytometry? | Not applicable,No,Unknown,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Specify method(s) that was used to assess measurable residual disease status (check all that apply) | FISH, Karyotyping, Flow Cytometry, PCR, NGS, Not assessed | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by FISH? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by karyotyping assay? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Which leukemia phenotype was used for detection (check all the apply) | original leukemia immunophenotype, aberrant phenotype | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
What is the lower limit of detection (for the original leukemia immunophenotype) | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
What is the lower limit of detection (for the aberrant phenotype) | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by flow cytometry? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by PCR? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Acute Lymphoblastic Leukemia (ALL) | yes | no | Addition of Information Requested |
Was measurable residual disease detected by NGS? | no,yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Disease Classification | Myelodysplastic Syndrome (MDS) | yes | no | Specify the cell line examined to determine HI status | HI-E,HI-N,HI-P | Change/Clarification of Information Requested | Specify the cell lines examined to determine HI status | HI-E,HI-N,HI-P | Examples added or typographical errors corrected for clarification |
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Specify the lymphoma histology | Hodgkin Lymphoma 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 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- Activated B-cell type (non-GCB) (1821) Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) Diffuse large B-cell Lymphoma (cell of origin unknown) (107) 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, 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, predominantly small cleaved cell (Grade I follicle center lymphoma) (102) 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 DLBCL, leg type (1822) Primary cutaneous follicle center lymphoma (1817) Primary diffuse, large B-cell lymphoma of the CNS (118) Primary effusion lymphoma (138) Primary mediastinal (thymic) large B-cell lymphoma (125) Splenic B-cell lymphoma/leukemia, unclassifiable (1811) Splenic diffuse red pulp small B-cell lymphoma (1812) Splenic marginal zone B-cell lymphoma (124) T-cell / histiocytic rich large B-cell lymphoma (120) Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173) Other B-cell lymphoma (129) – Go to question 380 T-cell and NK-cell Neoplasms Adult T-cell lymphoma / leukemia (HTLV1 associated) (134) Aggressive NK-cell leukemia (27) Anaplastic large-cell lymphoma (ALCL), ALK positive (143) Anaplastic large-cell lymphoma (ALCL), ALK negative (144) Angioimmunoblastic T-cell lymphoma (131) Breast implant–associated anaplastic large-cell lymphoma (1861) Chronic lymphoproliferative disorder of NK cells (1856) Enteropathy-type T-cell lymphoma (133) Extranodal NK / T-cell lymphoma, nasal type (137) 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 acral CD8+ T-cell lymphoma (1853) Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (1854) Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1852) Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell lymphoma (C-ALCL), lymphoid papulosis] (147) Primary cutaneous γδ T-cell lymphoma (1851) 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) 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) |
Change/Clarification of Response Options | Specify the lymphoma histology | Classical Hodgkin Lymphoma Lymphocyte depleted (154) Lymphocyte-rich (151) Mixed cellularity (153) Nodular sclerosis (152) Other Classical Hodgkin Lymphoma Hodgkin lymphoma, not otherwise specified (150) Nodular lymphocyte predominant Hodgkin lymphoma Non-Hodgkin Lymphoma 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- Activated B-cell type (non-GCB) (1821) Diffuse, large B-cell lymphoma- Germinal center B-cell type (1820) Diffuse large B-cell Lymphoma (cell of origin unknown) (107) 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, 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, predominantly small cleaved cell (Grade I follicle center lymphoma) (102) 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 DLBCL, leg type (1822) Primary cutaneous follicle center lymphoma (1817) Primary diffuse, large B-cell lymphoma of the CNS (118) Primary effusion lymphoma (138) Primary mediastinal (thymic) large B-cell lymphoma (125) Splenic B-cell lymphoma/leukemia, unclassifiable (1811) Splenic diffuse red pulp small B-cell lymphoma (1812) Splenic marginal zone B-cell lymphoma (124) T-cell / histiocytic rich large B-cell lymphoma (120) Waldenstrom macroglobulinemia / Lymphoplasmacytic lymphoma (173) Other B-cell lymphoma (129) – Go to question 380 T-cell and NK-cell Neoplasms Adult T-cell lymphoma / leukemia (HTLV1 associated) (134) Aggressive NK-cell leukemia (27) Anaplastic large-cell lymphoma (ALCL), ALK positive (143) Anaplastic large-cell lymphoma (ALCL), ALK negative (144) Angioimmunoblastic T-cell lymphoma (131) Breast implant–associated anaplastic large-cell lymphoma (1861) Chronic lymphoproliferative disorder of NK cells (1856) Enteropathy-type T-cell lymphoma (133) Extranodal NK / T-cell lymphoma, nasal type (137) 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 acral CD8+ T-cell lymphoma (1853) Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (1854) Primary cutaneous CD8+ aggressive epidermotropic cytotoxic T-cell lymphoma (1852) Primary cutaneous CD30+ T-cell lymphoproliferative disorders [Primary cutaneous anaplastic large-cell lymphoma (C-ALCL), lymphoid papulosis] (147) Primary cutaneous γδ T-cell lymphoma (1851) 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) 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) |
Be consistent with current clinical landscape, improve transplant outcome data |
| Disease Classification | Hodgkin and Non-Hodgkin Lymphoma | yes | no | Is the lymphoma histology reported at transplant a transformation from CLL? | no,yes | Change/Clarification of Response Options | Is the lymphoma histology reported at transplant a transformation from CLL? | no,yes (Also complete Chronic Lymphocytic Leukemia (CLL) ) | Capture additional relevent disease information |
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Plasma cells in blood by flow cytometry | Known,Unknown | Change/Clarification of Information Requested | Plasma cells in peripheral blood by flow cytometry | Known,Unknown | Capture data accurately |
| Disease Classification | Multiple Myeloma / Plasma Cell Disorder (PCD) | yes | no | Plasma cells in blood by morphologic assessment | Known,Unknown | Change/Clarification of Information Requested | Plasma cells in peripheral blood by morphologic assessment | Known,Unknown | Capture data accurately |
| Disease Classification | Inherited Bone Marrow Failure Syndromes | yes | no | Specify the inherited bone marrow failure syndrome classification | Dyskeratosis congenita,Fanconi anemia,Severe congenital neutropenia,Diamond-Blackfan anemia,Shwachman-Diamond | Change/Clarification of Response Options | Specify the inherited bone marrow failure syndrome classification | Dyskeratosis congenita,Fanconi anemia,Severe congenital neutropenia,Diamond-Blackfan anemia,Shwachman-Diamond, Other inherited bone failure syndromes | Be consistent with current clinical landscape, improve transplant outcome data |
| Disease Classification | Inherited Bone Marrow Failure Syndromes | yes | no | Did the recipient receive gene therapy to treat the inherited bone marrow failure syndrome? | No,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Disease Classification | Hemoglobinopathies | yes | no | Did the recipient receive gene therapy to treat the hemoglobinopathy? | No,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Disease Classification | Inherited Disorders of Metabolism | yes | no | Specify inherited disorders of metabolism classification | Adrenoleukodystrophy (ALD) (543),Aspartyl glucosaminidase (561),ß-glucuronidase deficiency (VII) (537),Fucosidosis (562),Gaucher disease (541),Glucose storage disease (548),Hunter syndrome (II) (533),Hurler syndrome (IH) (531),I-cell disease (546),Krabbe disease (globoid leukodystrophy) (544),Lesch-Nyhan (HGPRT deficiency) (522),Mannosidosis (563),Maroteaux-Lamy (VI) (536),Metachromatic leukodystrophy (MLD) (542),Mucolipidoses, not otherwise specified (540),Morquio (IV) (535),Mucopolysaccharidosis (V) (538),Mucopolysaccharidosis, not otherwise specified (530),Niemann-Pick disease (545),Neuronal ceroid lipofuscinosis (Batten disease) (523),Other inherited metabolic disorder (529),Osteopetrosis (malignant infantile osteopetrosis) (521),Polysaccharide hydrolase abnormality, not otherwise specified (560),Sanfilippo (III) (534),Scheie syndrome (IS) (532),Inherited metabolic disorder, not otherwise specified (520),Wolman disease (547) | Change/Clarification of Response Options | Specify inherited disorders of metabolism classification | Hereditary diffuse leukoencephalopathy with spheroids, Adrenoleukodystrophy (ALD) (543),Aspartyl glucosaminidase (561),ß-glucuronidase deficiency (VII) (537),Fucosidosis (562),Gaucher disease (541),Glucose storage disease (548),Hunter syndrome (II) (533),Hurler syndrome (IH) (531),I-cell disease (546),Krabbe disease (globoid leukodystrophy) (544),Lesch-Nyhan (HGPRT deficiency) (522),Mannosidosis (563),Maroteaux-Lamy (VI) (536),Metachromatic leukodystrophy (MLD) (542),Mucolipidoses, not otherwise specified (540),Morquio (IV) (535),Mucopolysaccharidosis (V) (538),Mucopolysaccharidosis, not otherwise specified (530),Niemann-Pick disease (545),Neuronal ceroid lipofuscinosis (Batten disease) (523),Other inherited metabolic disorder (529),Osteopetrosis (malignant infantile osteopetrosis) (521),Polysaccharide hydrolase abnormality, not otherwise specified (560),Sanfilippo (III) (534),Scheie syndrome (IS) (532),Inherited metabolic disorder, not otherwise specified (520),Wolman disease (547) | Be consistent with current clinical landscape, improve transplant outcome data |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | no | Specify the shipping environment of the product(s) | Room temperature, Cooled (refrigerator temperature, not frozen), Frozen (cyropreserved), Other shipping enfivronment | Change/Clarification of Response Options | Specify the shipping environment of the product(s) | Room temperature, Cooled (refrigerated gel pack, refrigerator temperature, not frozen), Frozen (cyropreserved), Other shipping enfivronment | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing TNC viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing TNC viability | Flow cytometry based (7AAD, AOPI, AOEB),Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing CD34+ cell viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing CD34+ cell viability | Flow cytometry based (7AAD, AOPI, AOEB), Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing CD3+ cell viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing CD3+ cell viability | Flow cytometry based (7AAD, AOPI, AOEB), Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing CD3+CD4+ cell viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing CD3+CD4+ cell viability | Flow cytometry based (7AAD, AOPI, AOEB), Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Infusion Product | no | yes | Method of testing CD3+CD8+ cell viability | Flow cytometry based,Other method,Trypan blue | Change/Clarification of Response Options | Method of testing CD3+CD8+ cell viability | Flow cytometry based (7AAD, AOPI, AOEB), Other method,Trypan blue | Examples added or typographical errors corrected for clarification | |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total CFU-GM | Done,Not done | Merged to Check all that Apply | Indicate which Assessments were Carried out (Check all that apply) | Total CFU-GM, Total CFU-GEMM, Total BFU-E | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total CFU-GEMM | Done,Not done | Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Cord Blood Product Infusion | yes | yes | Total BFU-E | Done,Not done | Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | ||
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Product Analysis | yes | yes | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methacillin Resistant), 179 Staphylococcus aureus (Methacillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Change/Clarification of Response Options | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methicillin Resistant), 179 Staphylococcus aureus (Methicillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Examples added or typographical errors corrected for clarification |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Product Analysis | yes | yes | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methacillin Resistant), 179 Staphylococcus aureus (Methacillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Change/Clarification of Response Options | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methicillin Resistant), 179 Staphylococcus aureus (Methicillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Examples added or typographical errors corrected for clarification |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Product Analysis | yes | yes | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methacillin Resistant), 179 Staphylococcus aureus (Methacillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Change/Clarification of Response Options | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methicillin Resistant), 179 Staphylococcus aureus (Methicillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Examples added or typographical errors corrected for clarification |
| Hematopoietic Cellular Transplant (HCT) Product Infusion | Product Analysis | yes | yes | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methacillin Resistant), 179 Staphylococcus aureus (Methacillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Change/Clarification of Response Options | Specify Organism Code(s): | Bacterial Infections: 121 inetobacter (all species), 125 Bordetella pertussis (whooping cough), 128 Campylobacter (all species), 129 Capnocytophaga (all species), 171 Chlamydia (pneumoniae), 130 Citrobacter (freundii, other species), 131 Clostridium (all species except difficile), 132 Clostridium difficile, 173 Corynebacterium jeikeium, 134 Enterobacter (all species), 135 Enterococcus (all species), 177 Enterococcus, vancomycin resistant (VRE), 136 Escherichia (also E. coli), 139 Fusobacterium (all species), 187 Haemophilus influenzae, 188 Haemophilus non-influenzae, 146 Klebsiella (all species), 147 Lactobacillus (bulgaricus, acidophilus, other species), 189 Legionella pneumophila, 190 Legionella non-pneumophila, 103 Leptospira (all species), 148 Leptotrichia buccalis, 149 Leuconostoc (all species), 104 Listeria monocytogenes, 151 Micrococcus, NOS, 118 Mycobacterium abscessus, 112 Mycobacterium avium - intracellulare (MAC, MAI), 108 Mycobacterium cheloneae, 109 Mycobacterium fortuitum, 114 Mycobacterium haemophilum, 115 Mycobacterium kansasii, 116 Mycobacterium marinum, 117 Mycobacterium mucogenicum, 110 Mycobacterium tuberculosis (tuberculosis, Koch bacillus), 105 Mycoplasma (all species), 183 Neisseria gonorrhoeae, 184 Neisseria meningitidis, 106 Nocardia (all species), 153 Pasteurella multocida, 155 Proteus (all species), 157 Pseudomonas or Burkholderia cepacia, 185 Pseudomonas aeruginosa, 186 Pseudomonas non-aeruginosa, 159 Rhodococcus (all species), 107 Rickettsia (all species), 160 Salmonella (all species), 161 Serratia marcescens,162 Shigella (all species), 180 Staphylococcus aureus (Methicillin Resistant), 179 Staphylococcus aureus (Methicillin Sensitive), 158 Stenotrophomonas maltophilia, 166 Stomatococcus mucilaginosis, 181 Streptococcus, alpha-hemolytic, 182 Streptococcus, Group B, 178 Streptococcus pneumoniae, 168 Treponema (syphilis), 169 Vibrio (all species) Fungal Infections: 210 Aspergillus, NOS, 211 Aspergillus flavus, 212 Aspergillus fumigatus, 213 Aspergillus niger, 215 Aspergillus terreus, 214 Aspergillus ustus, 270 Blastomyces (dermatitidis), 201 Candida albicans, 208 Candida non-albicans, 271 Coccidioides (all species), 222 Cryptococcus gattii, 221 Cryptococcus neoformans, 230 Fusarium (all species), 261 Histoplasma (capsulatum), 241 Mucorales (all species), 260 Pneumocystis (PCP / PJP), 242 Rhizopus (all species), 272 Scedosporium (all species), 240 Zygomycetes, NOS, 503 Suspected fungal infection, 777 Other organism | Examples added or typographical errors corrected for clarification |
| Post-Transplant Essential Data | no | yes | Specify the recipient's survival status at the date of last contact | Alive,Dead | Change/Clarification of Response Options | Specify the recipient's survival status at the date of last contact | Alive,Dead (Complete recipient death data) | Capture additional relevent disease information | |
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Addition of Information Requested |
Was this infusion a donor lymphocyte infusion (DLI)? | no,yes | Capture additional relevent disease information | ||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Addition of Information Requested |
Number of DLIs in this reporting period | __ __ | Capture additional relevent disease information | ||
| Post-Transplant Essential Data | Subsequent Transplant | yes | yes | Addition of Information Requested |
Are any of the products, associated with this course of cellular therapy, genetically modified? | no, yes | Capture additional relevent disease information | ||
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Date maximum overall grade of acute GVHD: | YYYY/MM/DD | Change/Clarification of Information Requested | First date maximum overall grade of acute GVHD: | YYYY/MM/DD | Capture data accurately |
| Post-Transplant Essential Data | Graft vs. Host Disease | yes | yes | Date estimated | checked | Deletion of Information: Merged to Check all that Apply | Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | ||
| Post-Transplant Essential Data | no | yes | Specify therapy (check all that apply) | Defibrotide,N-acetylcysteine,Other therapy,Tissue plasminogen activator (TPA),Ursodiol | Change/Clarification of Response Options | Specify therapy (check all that apply) | Defibrotide,N-acetylcysteine,Other therapy,Tissue plasminogen activator (TPA),Ursodiol, Enoxaparin (Lovenox), Heparin | Be consistent with current clinical landscape, improve transplant outcome data | |
| Post-Transplant Essential Data | no | yes | Did a new malignancy, myelodysplastic, myeloproliferative, or lymphoproliferative disease / disorder occur that is different from the disease / disorder for which the HCT or cellular therapy was performed? | No,Yes | Change/Clarification of Response Options | Did a new malignancy, myelodysplastic, myeloproliferative, or lymphoproliferative disease / disorder occur that is different from the disease / disorder for which the HCT or cellular therapy was performed? | No,Yes (Also complete Subsequent Neoplasms) , previosly reported | Capture additional relevent disease information | |
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Date of birth: | YYYY/MM/DD | Change/Clarification of Information Requested | Donor Date of birth: | YYYY/MM/DD | Capture data accurately |
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Sex | female,male | Change/Clarification of Information Requested | Donor Sex | female,male | Capture data accurately |
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Method | Fluorescent in situ hybridization (FISH) for XX/XY,Karyotyping for XX/XY,Other,Restriction fragment-length polymorphisms (RFLP),VNTR or STR, micro or mini satellite | Change/Clarification of Response Options | Method | PCR(includes quantitative, real time, and fluorescent multiplex), Fluorescent in situ hybridization (FISH) for XX/XY,Karyotyping for XX/XY,Other,Restriction fragment-length polymorphisms (RFLP),VNTR or STR, micro or mini satellite | Examples added or typographical errors corrected for clarification |
| Post-Transplant Essential Data | Chimerism Study Performed | yes | yes | Were donor cells detected? | No,Yes | Deletion of Information Requested | Reduce redundancy in data capture | ||
| Post-HCT Therapy | no | yes | Specify systemic therapy (check all that apply) | Alemtuzumab,Azacytidine,Blinatumomab,Bortezomib,Bosutinib,Carfilzomib,Chemotherapy,Dasatinib,Decitabine,Gemtuzumab,Gilteritinib,Ibrutinib,Imatinib mesylate,Ixazomib,Lenalidomide,Lestaurtinib,Midostaurin,Nilotinib,Nivolumab,Other systemic therapy,Pembrolizumab,Pomalidomide,Quizartinib,Rituximab,Sorafenib,Sunitinib,Thalidomide | Change/Clarification of Response Options | Specify systemic therapy (check all that apply) | Alemtuzumab,Azacytidine,Blinatumomab,Bortezomib,Bosutinib,Carfilzomib,Chemotherapy,Dasatinib,Decitabine,Gemtuzumab,Gilteritinib,Ibrutinib,Imatinib mesylate,Ixazomib,Lenalidomide,Lestaurtinib,Midostaurin,Nilotinib,Nivolumab,Other systemic therapy,Pembrolizumab,Pomalidomide,Quizartinib,Rituximab,Sorafenib,Sunitinib,Thalidomide, Brentuximab vendotin, Daratumumab (Darzalex) | Be consistent with current clinical landscape, improve transplant outcome data | |
| Post-HCT Therapy | no | yes | Addition of Information Requested |
Did a fecal microbiota transplant (FMT) occur since the date of last report? | No, Yes | Be consistent with current clinical landscape, improve transplant outcome data | |||
| Post-HCT Therapy | no | yes | Addition of Information Requested |
Date of FMT | DD/MM/YY | Be consistent with current clinical landscape, improve transplant outcome data | |||
| Post-HCT Therapy | no | yes | Addition of Information Requested |
Specify the indication for the FMT | Graft versus host disease (GVHD), Clostridium difficle, Other | Be consistent with current clinical landscape, improve transplant outcome data | |||
| Post-HCT Therapy | no | yes | Addition of Information Requested |
Specify other indication: | open text | Be consistent with current clinical landscape, improve transplant outcome data | |||
| Relapse or Progression Post-HCT | no | yes | Specify systemic therapy (check all that apply) | Alemtuzumab,Azacytidine,Blinatumomab,Bortezomib,Bosutinib,Carfilzomib,Chemotherapy,Dasatinib,Decitabine,Gemtuzumab,Gilteritinib,Ibrutinib,Imatinib mesylate,Ixazomib,Lenalidomide,Lestaurtinib,Midostaurin,Nilotinib,Nivolumab,Other systemic therapy,Pembrolizumab,Pomalidomide,Quizartinib,Rituximab,Sorafenib,Sunitinib,Thalidomide | Change/Clarification of Response Options | Specify systemic therapy (check all that apply) | Alemtuzumab,Azacytidine,Blinatumomab,Bortezomib,Bosutinib,Carfilzomib,Chemotherapy,Dasatinib,Decitabine,Gemtuzumab,Gilteritinib,Ibrutinib,Imatinib mesylate,Ixazomib,Lenalidomide,Lestaurtinib,Midostaurin,Nilotinib,Nivolumab,Other systemic therapy,Pembrolizumab,Pomalidomide,Quizartinib,Rituximab,Sorafenib,Sunitinib,Thalidomide, Daratumumb (Darzalex), Venetoclax | Be consistent with current clinical landscape, improve transplant outcome data | |
| Current Disease Status | no | yes | Date of most recent disease assessment | Known,Unknown | Deletion of Information Requested | Reduce redundancy in data capture | |||
| Current Disease Status | no | yes | Date of most recent disease assessment: | YYYY/MM/DD | Change/Clarification of Information Requested | Date of most recent disease assessment Date of assesment of current disease status | YYYY/MM/DD | Reduce redundancy in data capture | |
| Recipient Death Data | Recipient Death | yes | no | Addition of Information Requested |
Date of death: | YYYY/MM/DD | Reduce redundancy in data capture | ||
| Recipient Death Data | Recipient Death | yes | no | Addition of Information Requested |
Date estimated | checked | Reduce redundancy in data capture | ||
| Recipient Death Data | Recipient Death | yes | no | Addition of Information Requested |
Was cause of death confirmed by autopsy? | Autopsy pending,No,Unknown,Yes | Reduce redundancy in data capture | ||
| Recipient Death Data | Recipient Death | yes | no | Addition of Information Requested |
Was documentation submitted to the CIBMTR? | No,Yes | Reduce redundancy in data capture | ||
| Recipient Death Data | Recipient Death | yes | no | Primary cause of death | Accidental death,Acute GVHD,Adult respiratory distress syndrome (ARDS) (other than IPS),Bacterial infection,Cardiac failure,Chronic GVHD,Central nervous system (CNS) failure,COVID-19 (SARS-CoV-2),Cytokine release syndrome,Diffuse alveolar damage (without hemorrhage), Disseminated intravascular coagulation (DIC),Fungal infection, Gastrointestinal (GI) failure (not liver),Graft rejection or failure, Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)),Idiopathic pneumonia syndrome (IPS), Liver failure (not VOD),Multiple organ failure,New malignancy,Infection, organism not identified,Other cause, Other infection,Other organ failure,Other pulmonary syndrome (excluding pulmonary hemorrhage),Other vascular,Prior malignancy,Protozoal infection, Pulmonary failure,Recurrence / persistence / progression of disease,Renal failure,Suicide,Thromboembolic, Pneumonitis due to Cytomegalovirus (CMV),Viral infection,Pneumonitis due to other virus,Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) | Change/Clarification of Response Options | Primary cause of death | Accidental death,Acute GVHD,Adult respiratory distress syndrome (ARDS) (other than IPS),Bacterial infection,Cardiac failure,Chronic GVHD,Central nervous system (CNS) failure,COVID-19 (SARS-CoV-2),Cytokine release syndrome,Diffuse alveolar damage (without hemorrhage),Diffuse alveolar hemorrhage (DAH),Disseminated intravascular coagulation (DIC),Fungal infection,Gastrointestinal hemorrhage,Gastrointestinal (GI) failure (not liver),Graft rejection or failure,Hemorrhagic cystitis,Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)),Idiopathic pneumonia syndrome (IPS),Intracranial hemorrhage,Liver failure (not VOD),Multiple organ failure,New malignancy,Infection, organism not identified,Other cause,Other hemorrhage neurotoxicity (ICANS), Other infection,Other organ failure,Other pulmonary syndrome (excluding pulmonary hemorrhage),Other vascular,Prior malignancy,Protozoal infection,Pulmonary hemorrhage,Pulmonary failure,Recurrence / persistence / progression of disease,Renal failure,Suicide,Thromboembolic, Tumor lysis syndrome, Pneumonitis due to Cytomegalovirus (CMV),Viral infection,Pneumonitis due to other virus,Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) | Be consistent with current clinical landscape, improve transplant outcome data |
| Recipient Death Data | Recipient Death | yes | no | Contributing cause of death | Accidental death,Acute GVHD,Adult respiratory distress syndrome (ARDS) (other than IPS),Bacterial infection,Cardiac failure,Chronic GVHD,Central nervous system (CNS) failure,COVID-19 (SARS-CoV-2),Cytokine release syndrome,Diffuse alveolar damage (without hemorrhage), Disseminated intravascular coagulation (DIC),Fungal infection, Gastrointestinal (GI) failure (not liver),Graft rejection or failure, Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)),Idiopathic pneumonia syndrome (IPS), Liver failure (not VOD),Multiple organ failure,New malignancy,Infection, organism not identified,Other cause, Other infection,Other organ failure,Other pulmonary syndrome (excluding pulmonary hemorrhage),Other vascular,Prior malignancy,Protozoal infection, Pulmonary failure,Recurrence / persistence / progression of disease,Renal failure,Suicide,Thromboembolic, Pneumonitis due to Cytomegalovirus (CMV),Viral infection,Pneumonitis due to other virus,Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) | Change/Clarification of Response Options | Contributing cause of death | Accidental death,Acute GVHD,Adult respiratory distress syndrome (ARDS) (other than IPS),Bacterial infection,Cardiac failure,Chronic GVHD,Central nervous system (CNS) failure,COVID-19 (SARS-CoV-2),Cytokine release syndrome,Diffuse alveolar damage (without hemorrhage),Diffuse alveolar hemorrhage (DAH),Disseminated intravascular coagulation (DIC),Fungal infection,Gastrointestinal hemorrhage,Gastrointestinal (GI) failure (not liver),Graft rejection or failure,Hemorrhagic cystitis,Thrombotic microangiopathy (TMA) (Thrombotic thrombocytopenic purpura (TTP)/Hemolytic Uremic Syndrome (HUS)),Idiopathic pneumonia syndrome (IPS),Intracranial hemorrhage,Liver failure (not VOD),Multiple organ failure,New malignancy,Infection, organism not identified,Other cause,Other hemorrhage neurotoxicity (ICANS), Other infection,Other organ failure,Other pulmonary syndrome (excluding pulmonary hemorrhage),Other vascular,Prior malignancy,Protozoal infection,Pulmonary hemorrhage,Pulmonary failure,Recurrence / persistence / progression of disease,Renal failure,Suicide,Thromboembolic, Tumor lysis syndrome, Pneumonitis due to Cytomegalovirus (CMV),Viral infection,Pneumonitis due to other virus,Veno-occlusive disease (VOD) / sinusoidal obstruction syndrome (SOS) | Be consistent with current clinical landscape, improve transplant outcome data |
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Specify the new malignancy | Hematologic Malignancy: Acute myeloid leukemia (AML / ANLL), Other leukemia, Myelodysplastic syndrome (MDS), Myeloproliferative neoplasm (MPN), Overlapping myelodysplasia / myeloproliferative neoplasm (MDS / MPN), Hodgkin lymphoma, Non-Hodgkin lymphoma, Clonal cytogenetic abnormality without leukemia or MDS, Uncontrolled proliferation of donor cells without malignant transformation Solid Tumors: Oropharyngeal cancer (e.g. tongue, mouth, throat), Gastrointestinal malignancy (e.g. esophagus, stomach, small intestine, colon, rectum, anus, liver, pancreas), Lung cancer, Melanoma, Squamous cell skin malignancy, Basal cell skin malignancy, Breast cancer, Genitourinary malignancy (e.g. kidney, bladder, cervix, uterus, ovary, prostate, testis), Central nervous system (CNS) malignancy (e.g. meningioma, glioma), Thyroid cancer |
Change/Clarification of Response Options | Specify the new malignancy | Hematologic Malignancy: Acute myeloid leukemia (AML / ANLL), Acute lymphoblastic leukemia (ALL), Other leukemia, Myelodysplastic syndrome (MDS), Myeloproliferative neoplasm (MPN), Overlapping myelodysplasia / myeloproliferative neoplasm (MDS / MPN), Hodgkin lymphoma, Non-Hodgkin lymphoma, Multiple myeloma / plasma cell neoplasms, Clonal cytogenetic abnormality without leukemia or MDS, Uncontrolled proliferation of donor cells without malignant transformation. Solid Tumors: Bone sarcoma (regardless of site), Soft tissue sarcoma (regardless of site), Oropharyngeal cancer (e.g. tongue, mouth, throat), Gastrointestinal malignancy (e.g. esophagus, stomach, small intestine, colon, rectum, anus, liver, pancreas), Lung cancer, Melanoma, Squamous cell skin malignancy, Basal cell skin malignancy, Breast cancer, Genitourinary malignancy (e.g. kidney, bladder, cervix, uterus, ovary, prostate, testis), Central nervous system (CNS) malignancy (e.g. meningioma, glioma), Thyroid cancer |
Be consistent with current clinical landscape, improve transplant outcome data |
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was post-transplant lymphoproliferative disorder (PTLD) diagnosed? | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify type of PTLD | Monomorphic,Polymorphic,Unknown | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify oropharyngeal cancer | Mouth,Throat,Tongue, Other oropharyngeal cancer | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify gastrointestinal malignancy | Anus,Colon,Esophagus,Liver ,Pancreas,Rectum,Small intestine (DUODENUM, JEJUNUM, ILEUM),Stomach, Other gastrointestinall cancer | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify genitourinary malignancy | Bladder,Cervix,Kidney,Ovary,Prostate,Testicle,Uterus, Other genitourary malignancy | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify CNS malignancy | Glioma,Meningioma,Other CNS malignancy | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was PTLD confirmed by biopsy? | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was documentation submitted to the CIBMTR? (e.g. pathology report) | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was there EBV reactivation in the blood? | No,Not Done,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
How was EBV reactivation diagnosed? | Other method,Qualitative PCR of blood,Quantitative PCR of blood | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify other method: | open text | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Quantitative EBV viral load of blood: At diagnosis | _____ copies/ml | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was a quantitative PCR of blood performed again after diagnosis? | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Highest EBV viral load of blood: | ______copies/ml | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Was there lymphomatous involvement? | No,Yes | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify sites of PTLD involvement (check all that apply) | Bone marrow,Central nervous system (brain or cerebrospinal fluid),Liver,Lung,Lymph node(s),Other,Spleen | Be consistent with current clinical landscape, improve transplant outcome data | ||
| Subsequent Neoplasms | New Malignancy, Lymphoproliferative or Myeloproliferative Disease / Disorder | yes | yes | Addition of Information Requested |
Specify other site: | open text | Be consistent with current clinical landscape, improve transplant outcome data |
Sheet 6: pull down menus
| Below are pull down options for Column U: Do not delete | Below are pull down options for Column O: Do not delete |
| Reduce burden: expanded response options to include responses previously reported manually or created a "check all that apply" | Addition of Information Requested |
| Be consistent with current clinical landscape, improve transplant outcome data | Deletion of Information Requested |
| Capture data accurately | Merged to Check all that Apply |
| Examples added or typographical/grammatical errors corrected for clarification | Change/Clarification of Information Requested and Response Option |
| Covid-19 Impact | Change/Clarification of Information Requested |
| Capture additional relevent disease information | Change/Clarification of Response Options |
| Reduce redundancy in data capture |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |
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