TESTING TO BE PERFORMED DURING DONOR MEDICAL EXAMINATION
(To be sent by the donor registry to the transplant center for completion) (Page 1 of 2)
PATIENT
Patient Name:
Patient ID number:
(assigned by patient’s registry)
Transplant Center:
Patient ID number:
(assigned by donor’s registry)
DONOR
Donor ID
Donor Registry:
At the time of donor physical examination, the donor center will automatically perform the tests listed as “Automatically
tested”. If you would like tests performed that are listed as “Will test upon request”, please check the box “Please perform”.
Any test marked as “Cannot test” will need to be performed at the transplant center laboratory. IF THIS WILL CHANGE
THE VOLUME OF BLOOD TO BE COLLECTED AT THE DONOR PHYSICAL EXAMINATION, PLEASE COMPLETE
AND RETURN A REVISED PRESCRIPTION FORM AS SOON AS POSSIBLE.
TEST INFORMATION
IDM
REGISTRY ABILITY TO PERFORM TEST
HEPATITIS B VIRUS (HBV)
HBs Ag
 Automatically tested
 Cannot Test
(Hepatitis B surface antigen screening test)
 Will test upon request
 Please perform
Anti-HBc
 Automatically tested
 Cannot Test
(Hepatitis B core antibody)
 Will test upon request
 Please perform
HEPATITIS C VIRUS (HCV)
Anti-HCV
 Automatically tested
 Cannot Test
(Hepatitis C antibody screening test)
 Will test upon request
 Please perform
HCV
 Automatically tested
(Hepatitis C virus)
 Will test upon request
 Please perform
(RIBA confirmatory test)
 Cannot Test
NHCV
 Automatically tested
 Cannot Test
(NAT Hepatitis C virus test)
 Will test upon request
 Please perform
HUMAN T-LYMPHOTROPIC VIRUSES
Anti-HTLV I/II
 Automatically tested
 Cannot Test
(screening test)
 Will test upon request
 Please perform
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
HIV-1 p24 antigen
 Automatically tested
 Cannot Test
(screening test)
 Will test upon request
 Please perform
HIV Nucleic Acid Amplification Technique (NAT testing)
 Automatically tested
 Cannot Test
 Will test upon request
 Please perform
Anti-HIV1 and Anti-HIV2 (antibodies to human
 Automatically tested
 Cannot Test
immunodeficiency viruses – screening test)
 Will test upon request
 Please perform
SYPHILIS
STS
 Automatically tested
 Cannot Test
(serologic test for syphilis)
 Will test upon request
 Please perform
Cytomegalovirus (CMV) antibodies
 both IgM and IgG
 total
WNV-NAT Testing
(West Nile Virus)
OTHER
 Automatically tested
 Will test upon request
 Cannot Test
 Automatically tested
 Will test upon request
 Please perform
 Cannot Test
 Please perform
WMDA/DRWG/IDM Info v0 June 2004
ALT
 Automatically tested
 Cannot Test
 Will test upon request
 Please perform
Epstein Barr Virus (EBV) antibodies
 Automatically tested
 both IgM and IgG
 Will test upon request
 Please perform
 only IgG
 Cannot Test
Toxoplasmosis antibodies
 Automatically tested
 both IgM and IgG
 Will test upon request
 Please perform
 total
 Cannot Test
Please list any additional tests you would like the donor center to perform during the donor’s medical examination.
The donor center will inform you if these tests can be performed:
TRANSPLANT CENTER ACKNOWLEDGEMENT OF DONOR TESTING
I HAVE REVIEWED THE ABOVE LIST OF TESTS TO BE PERFORMED AT THE TIME OF THE DONOR PHYSICAL EXAMINATION BY
THE DONOR CENTER. ANY REQUESTS FOR ADDITIONAL TESTING TO BE PERFORMED BY THE DONOR CENTER HAVE BEEN
MADE USING THIS FORM. IF TESTING REQUIRED BY THE TRANSPLANT CENTER PROTOCOL CANNOT BE PERFORMED BY
THE DONOR CENTER LABORATORY, AN UPDATED PRESCRIPTION FORM WILL BE SUBMITTED TO THE DONOR CENTER
ADJUSTING THE PRE-COLLECTION BLOOD VOLUME (S) ACCORDINGLY.
Name of Person Completing Form:
Title:
Signature:
Date:
(Day/Month/Year)
INSTRUCTIONS FOR THE USE OF THE FOLLOWING FORM:
TESTING TO BE PERFORMED DURING DONOR MEDICAL EXAMINATION
The WMDA form:
TESTING TO BE PERFORMED DURING DONOR MEDICAL EXAMINATION,
is intended to allow each donor center to inform the requesting transplant center of tests to be performed during a donor’s
medical examination prior to stem cell donation. Once the donor center has completed the attached form, it should be
provided to the requesting transplant center immediately following receipt of a formal request for stem cell collection. It may
be necessary for a donor center to maintain more than one version of this form, if testing varies between collection centers
used by the donor center.
1. Save this form to a local computer.
2. For each test listed on this form, indicate your center’s ability to perform the respective tests by placing an ‘X” or “”
in the appropriate box.
o
o
o
If a test will be automatically be performed at the physical examination, tick “Automatically tested”.
If a test can be performed, but not automatically performed by your center, tick “Will test upon request”. The
transplant center will then tick “Please perform”, if they would like your center to perform this test.
If a test is unable to be performed by your center, tick “Cannot Test”. If this test is mandatory in the
transplant center protocol, the transplant center will then know that it is necessary to perform the testing at
the transplant center laboratory.
3. Each time your center receives a formal request for stem cell collection, provide this form to the requesting
transplant center for review, completion and signature. Even if the testing performed by your center is completely
acceptable, the transplant center should still indicate that the testing is acceptable, sign the form and return it to the
donor center.
WMDA/DRWG/IDM Info v0 June 2004