ANTHONY NOLAN
2 Heathgate Place
75-87 Agincourt Road
London NW3 2NU
www.anthonynolan.org
T:+ (44) 0303 303 0303
F: +(44) 0207 284 8226
Emergency: + (44) 07710 599161
E: [email protected]
Registered charity number
803716/SC038827
FORMAL REQUEST for SUBSEQUENT BLOOD STEM CELL or LYMPHOCYTE
COLLECTION
This only needs to be completed for a second donation from the same donor
(To be submitted with relevant prescription forms)
1. PATIENT DATA:
Recipient Initials :
Recipient ID:
(assigned by recipient’s TC/registry)
Recipient ID:
Recipient ID:
(assigned by Anthony Nolan)
(assigned by donor’s registry)
Pre-transplant diagnosis:
Disease status at time of initial transplant:
Date of birth:
Gender:
Weight (kg):
(Day/Month/Year)
CMV:
Current disease status:
ABO/ Rh:
Reason for subsequent donation request:
2. DONOR DATA: Information on currently requested donor
Donor ID:
Age or date of birth:
Gender:
Donor’s Registry:
Weight (kg):
(Day/Month/Year)
CMV:
Blood Group / Rh:
3. DATA FROM PREVIOUS TRANSPLANT:
Number of previous transplants:
Date of last stem cell
infusion:
Manipulation: (state type e.g. T-cell depletion, plasma removal etc.)
(Day/Month/Year)
Source of stem cells for last transplant:
In case of unrelated: donor ID, source of stem cells, date of donation:
Cell dose administered to
recipient:
Details on conditioning
treatment:
MARROW
x 10^8 / kg (NC)
Myeloablative
PBSC
x 10^6 / kg(CD34+)
dose-reduced
Did the conditioning regimen include TBI?
GvHD prophylaxis
administered:
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ANTHONY NOLAN
2 Heathgate Place
75-87 Agincourt Road
London NW3 2NU
www.anthonynolan.org
T:+ (44) 0303 303 0303
F: +(44) 0207 284 8226
Emergency: + (44) 07710 599161
E: [email protected]
Registered charity number
803716/SC038827
3. DATA FROM PREVIOUS TRANSPLANT (continued):
Was any portion of the
stem cell product frozen?
If YES, list the cell dose available:
Reason for freezing:
MARROW
PBSC
x 10^8 / kg (NC)
If any portion of the stem
cell product was frozen,
was it infused?
x 10^6 / kg(CD34+)
If YES, what was the date of infusion?
Reason for infusion:
Is autologous back up
marrow/PBSC available?
Collection date:
(Day/Month/Year)
4. ENGRAFTMENT DATA / DISEASE STATUS
Engraftment (neutrophils > 0.5 x 10^9/L)
Date
(Day/Month/Year)
In case of allogeneic SCT hematopoietic chimerism (most recent result with date):
Date:
Please state percentage: donor
%
recipient ________%
(Day/Month/Year)
Best response of disease to transplant:
Date achieved:
(Day/Month/Year)
Evaluated by:
Current disease status:
Date of assessment:
(Day/Month/Year)
Chromosome/PCR data (state source – marrow or blood) on disease and chimerism
Most recent result with date:
Evaluated by:
Additional comments:
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ANTHONY NOLAN
2 Heathgate Place
75-87 Agincourt Road
London NW3 2NU
www.anthonynolan.org
T:+ (44) 0303 303 0303
F: +(44) 0207 284 8226
Emergency: + (44) 07710 599161
E: [email protected]
Registered charity number
803716/SC038827
5. TRANSPLANT RELATED COMPLICATIONS IN PATIENT:
GVHD: (Grade/organs involved and treatment received)
Organs:
Acute:
Organs:
Chronic:
Grade
Grade
Resolved:
Resolved:
Serious infection: (State type and treatment received)
Resolved:
Organ toxicity/Other:
Describe type and treatment:
Resolved:
6. CURRENT CLINICAL STATUS OF PATIENT:
Physical examination: (state significant findings)
Current medication: (please list)
Describe any intensive medical support the recipient is receiving e.g. Ventilation, dialysis etc:
7. CURRENT RECIPIENT CONDITION (Laboratory Data):
(blanks will be taken to represent normal results)
WBC:
Haemoglobin ______g/dL
Date of last red cell transfusion:
WBC Differential:
Neutrophils
Blasts
Lymphocytes
Others
Frequency of red blood cell transfusions: ___________________
(Day/Month/Year)
Platelets ________x 10^9/L
Date of last platelet transfusion:
Frequency of platelet transfusions: _____________________
(Day/Month/Year)
Please give the following results only if abnormal:
Urea:
Creatinine:
Bilirubin:
mg/dL
mg/dL
mg/dL
AST:
Alkaline Phosphatase:
Chest X-Ray:
U/L
U/L
8. PREVIOUS REQUESTS FOR SUBSEQUENT DONATION:
Has there been a previous post transplant donation request for this donor?
Product requested:
If yes, was the request approved?
If the request was refused, state why:
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T:+ (44) 0303 303 0303
F: +(44) 0207 284 8226
Emergency: + (44) 07710 599161
E: [email protected]
Registered charity number
803716/SC038827
ANTHONY NOLAN
2 Heathgate Place
75-87 Agincourt Road
London NW3 2NU
www.anthonynolan.org
9. PRODUCT REQUEST:
Product preference:
Bone Marrow (BM)
Lymphocyte (unstimulated leucopheresis)
Stimulated PBSC
Bloods samples - specify:
Please fill in a numeric value next to product(s) to indicate preference:
1=1st preference; 2=2nd preference; 0=not desired even if 1st preference not possible
REASON FOR PRODUCT PREFERENCE: Please provide relevant information
Preferred collection date (Day/Month/Year)
Corresponding date of infusion (Day/Month/Year)
1
1
2
2
3
3
No. of days of conditioning prior to stem cell infusion:______
Minimum number of days prior to collection that donor clearance must be received:______
10. DETAILS ON PLANNED NEW SCT:
Is product manipulation planned?
If YES, briefly describe the planned manipulation:
Prophylaxis for GVHD:
Treatment alternative for patient besides Unrelated donor
Is a backup marrow/PBSC or frozen marrow/PBSC available?
Is there an alternative suitable unrelated donor?
Is there an alternative suitable unrelated cord blood unit?
Please state the expected response probability for your patient and describe the evidence for your
expectation:
Additional Comments:
11. REQUIRED DOCUMENTATION TO ACCOMPANY THIS REQUEST
Completed Marrow, PBSC or Unstimulated Leucopheresis Prescription Form(s)
(A prescription form is not required for a unit of blood)
12. TRANSPLANT CENTRE
Hospital:
Contact name:
Address:
Fax no:
Phone no:
Email:
ALL COMMUNICATIONS TO BE VIA ANTHONY NOLAN EXCEPT IN EMERGENCY
Person completing form:
Signature:
Date:
(Day/Month/Year)
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Formal Request for Subsequent Blood Stem Cell