Form 2006 R4 - Center for International Blood and Marrow

2006: Hematopoietic Cellular Transplant (HCT) Infusion Registry Use Only Sequence Number: Date Received: Key Fields OMB No: 0915-0310 Expiration Date: 12/31/2013 Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0310. Public reporting burden for this collection of information, in combination with the IDM Form 2004 and HLA Typing Form 2005, is estimated to average 1.5 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857. Sequence Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO Date Received: Date Received: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO CIBMTR Center Number: CIBMTR Center Number: ___ ___ ___ ___ ___ ELSE GOTO CIBMTR Recipient ID: CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO Date of HCT for which this form is being completed: Date of HCT for which this form is being completed: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO HCT type HCT type (check only one) O Autologous O Allogeneic, unrelated O Allogeneic, related ELSE GOTO Product type Product type (check only one) O Bone marrow O PBSC O Single cord blood unit O Other product IF Product type:= Other product THEN GOTO Specify: ELSE GOTO (1) Specify donor Specify: ________________________ ELSE GOTO (1) Specify donor CIBMTR Form 2006 revision 4 (page 1 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Donor/Cord Blood Unit Identification Questions: 1-15 1 Specify donor O Autologous O Autologous cord blood unit O NMDP unrelated cord blood unit O NMDP unrelated donor O Related donor O Related cord blood unit O Non-NMDP unrelated donor O Non-NMDP unrelated cord blood unit IF (1) Specify donor:= Autologous cord blood unit THEN GOTO (5) Non-NMDP CBU id ELSE GOTO (16) Did the donor receive therapy? IF (1) Specify donor:= NMDP unrelated cord blood unit THEN GOTO (2) NMDP Cord Blood Unit ID ELSE GOTO (16) Did the donor receive therapy? IF (1) Specify donor:= NMDP unrelated donor THEN GOTO (3) NMDP donor ID: ELSE GOTO (16) Did the donor receive therapy? IF (1) Specify donor:= Related donor THEN GOTO (10) Date of birth ELSE GOTO (16) Did the donor receive therapy? IF (1) Specify donor:= Related cord blood unit THEN GOTO (5) Non-NMDP CBU id ELSE GOTO (16) Did the donor receive therapy? IF (1) Specify donor:= Non-NMDP unrelated donor THEN GOTO (4) Non-NMDP donor id ELSE GOTO (16) Did the donor receive therapy? IF (1) Specify donor:= Non-NMDP unrelated cord blood unit THEN GOTO (5) Non-NMDP CBU id ELSE GOTO (16) Did the donor receive therapy? 2 NMDP cord blood unit ID: ________________________ IF (2) NMDP Cord Blood Unit ID:= EXISTS THEN GOTO (15) Was the product derived from an NMDP adult donor, NMDP cord blood unit, or non-NMDP cord blood unit? ELSE GOTO (3) NMDP donor ID: 3 NMDP donor ID: ________________________ IF (3) NMDP donor ID: := EXISTS THEN GOTO (15) Was the product derived from an NMDP adult donor, NMDP cord blood unit, or non-NMDP cord blood unit? ELSE GOTO (4) Non-NMDP donor id 4 Non-NMDP unrelated donor ID: ________________________ IF (4) Non-NMDP donor id:= EXISTS THEN GOTO (10) Date of birth ELSE GOTO (5) Non-NMDP CBU id 5 Non-NMDP cord blood unit ID: ________________________ ELSE GOTO (6) Is the CBU ID also the ISBT DIN number? (not applicable for related donor) (include related and autologous CBUs) 6 Is the CBU ID also the ISBT DIN number? O yes O no IF (6) Is the CBU ID also the ISBT DIN number?:= yes THEN GOTO (8) Registry or UCB Bank ID ELSE GOTO (7) Specify the ISBT DIN number: 7 Specify the ISBT DIN number: ________________________ CIBMTR Form 2006 revision 4 (page 2 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO (8) Registry or UCB Bank ID 8 Registry or UCB Bank ID O (A) Austrian Bone Marrow Donors O (ACB) Austrian Cord Blood Registry O (ACCB) StemCyte, Inc. O (AE) Emirates Bone Marrow Donor Registry O (AM) Armenian Bone Marrow Donor Registry Charitable Trust O (AOCB) University of Colorado Cord Blood Bank O (AR) Argentine CPH Donors Registry O (ARCB) BANCEL - Argentina Cord Blood Bank O (AUCB) Australian Cord Blood Registry O (AUS) Australian / New Zealand Bone Marrow Donor Registry O (B) Marrow Donor Program Belgium O (BCB) Belgium Cord Blood Registry O (BG) Bulgarian Bone Marrow Donor Registry O (BR) INCA/REDOMO O (BSCB) British Bone Marrow Registry - Cord Blood O (CB) Cord Blood Registry O (CH) Swiss BloodStem Cells - Adult Donors O (CHCB) Swiss Blood Stem Cells - Cord Blood O (CKCB) Celgene Cord Blood Bank O (CN) China Marrow Donor Program (CMDP) O (CNCB) Shan Dong Cord Blood Bank O (CND) Canadian Blood Services Bone Marrow Donor Registry O (CS2) Czech National Marrow Donor Registry O (CSCR) Czech Stem Cells Registry O (CY) Cyprus Paraskevaidio Bone Marrow Donor Registry O (CY2) The Cyprus Bone Marrow Donor Registry O (D) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Adult Donors O (DCB) ZKRD - Zentrales Knochenmarkspender - Register Deutschland Cord Blood O (DK) The Danish Bone Marrow Donor Registry O (DK2) Bone Marrow Donors Copenhagen (BMDC) O (DUCB) German Branch of the European Cord Blood Bank O (E) REDMO O (ECB) Spanish Cord Blood Registry O (F) France Greffe de Moelle - Adult Donors O (FCB) France Greffe de Moelle - Cord Blood O (FI) Finnish Bone Marrow Donor Registry O (FICB) Finnish Cord Blood Registry O (GB) The Anthony Nolan Trust O (GB3) Welsh Bone Marrow Donor Registry O (GB4) British Bone Marrow Registry O (GR) Unrelated Hematopoietic Stem Cell Donor Registry Greece O (GRCB) Michigan Community Blood Centers Cord Blood Bank O (H) Hungarian Bone Marrow Donor Registry O (HEM) Hema-Quebec O (HK) Hong Kong Bone Marrow Donor Registry O (HR) Croatian Bone Marrow Donor Registry O (I) Italian Bone Marrow Donor Registry O (I3CB) Sheba Medical Centre Cord Blood Registry O (ICB) Italian Cord Blood Bank Network O (IL) Hadassah BMDR O (IL2) Ezer Mizion Bone Marrow Donor Registry O (IL3) Sheba Medical Center Donor Registry O (ILCB) Isreal Cord Blood Bank O (IN) Asian Indian Donor Marrow Registry O (IN2) Dept. of Transfusion Medicine O (IRL) The Irish Unrelated Bone Marrow Panel O (JP) Japan Marrow Donor Program O (KR) Korea Marrow Donor Program O (LT) Lithuanian National Bone Marrow Donor Registry O (LVCB) Leuven Cord Blood Bank O (MACB) Victoria Angel Registry of Hope CIBMTR Form 2006 revision 4 (page 3 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O (MX) Mexican Bone Marrow Donor Registry O (N) The Norwegian Bone Marrow Donor Registry O (NL) Europdonor Foundation- Adult Donors O (NLCB) Europdonor Foundation - Cord Blood O (NYCB) National Cord Blood Program, New York Blood Center O (P) Portuguese Bone Marrow Donors Registry O (PL) National Polish Bone Marrow Registry O (PL2) Unrelated Bone Marrow Donor Registry -Adult Donors O (PL3) Against Leukemia Foundation Marrow Donor Registry O (PL4) Ursula Jaworska Foundation - Bone Marrow Donor Registry O (PL5) Polish Central Bone Marrow Donor Registry - Adult Donors O (PMCB) Elie Katz Umbilical Cord Blood Program O (R) Russian Bone Marrow Donor Registry O (R2) Karelian Registry of Unrelated Donors of Hematopoietic Stem Cells O (S) Tobias Registry of Swedish Bone Marrow Donors O (SG) Singapore Bone Marrow Donor Programme (BMDP) O (SK) Slovak National Bone Marrow Donor Registry O (SKCB) Eurocord Slovakia / Slovak Pacental Stem Cell Registry O (SLCBB) St Louis Cord Blood Bank O (SLO) Slovenia Donor O (SM) San Marino Bone Marrow Donor Registry O (T1CB) TRAN - Cord Blood O "(TACB) StemCyte, Inc. Taiwan" O "(TECB) Healthbanks Biotech, Co., Ltd " O (TH) Thai Stem Cell Donor Registry (TSCDR) O (TOCB) Tokyo Cord Blood Bank O (TPCB) BIONET / BabyBanks O (TRAN) TRAN - Adult Donors O (TRIS) Bone Marrow Bank of Istanbul Medical Faculty O (TW) Buddhist Tzu Chi Stem Cells Center - Adult Donors O (TWCB) Buddhist Tzu Chi Stem Cells Center - Cord Blood O (U1CB) National Marrow Donor Program - Cord Blood O (USA1) National Marrow Donor Program - Adult Donors O (USA2) America Bone Marrow Donor Registry O (UY) SINDOME O (VIAC) Viacord O (W3CB) Polish Central Bone Marrow Donor Registry - Cord Blood O (WACB) Unrelated Bone Marrow Donor Registry - Cord Blood O (ZA) South African Bone Marrow Registry O (OTH) Other Registry IF (8) Registry or UCB Bank ID := (OTH) Other Registry THEN GOTO (9) Specify other Registry or UCB Bank: ELSE GOTO (10) Date of birth 9 Specify other Registry or UCB Bank: ELSE GOTO (10) Date of birth ________________________ 10 Date of birth (donor/infant) O Known O Unknown IF (10) Date of birth:= Known THEN GOTO (11) Specify date of birth ELSE GOTO (12) Age 11 Date of birth: __ __ __ __ - __ __ - __ __ YYYY MM DD (donor/infant) IF (11) Specify date of birth:= EXISTS THEN GOTO (14) Sex ELSE GOTO (12) Age 12 Age (donor/infant) CIBMTR Form 2006 revision 4 (page 4 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O Known O Unknown IF (12) Age:= Known THEN GOTO (13) Specify age ELSE GOTO (14) Sex O Months (use only if less than 1 year old) ___ ___ ___ (donor/infant) O years ELSE GOTO Age units ELSE GOTO (14) Sex 13 Age: 14 Sex (donor/infant) O male O female ELSE GOTO (15) Was the product derived from an NMDP adult donor, NMDP cord blood unit, or non-NMDP cord blood unit? 15 Was the product derived from an NMDP adult donor, NMDP cord blood unit, or non-NMDP cord blood unit? O yes O no IF (15) Was the product derived from an NMDP adult donor, NMDP cord blood unit, or non-NMDP cord blood unit?:= yes THEN GOTO (43) Was this product collected off-site and shipped to your facility? ELSE GOTO (16) Did the donor receive therapy? Pre-Collection Therapy Questions: 16-27 16 Did the donor receive therapy, prior to any stem cell harvest, to enhance the product collection for this HCT? O yes O no IF (16) Did the donor receive therapy?:= yes THEN GOTO (17) Growth and mobilizing factor(s) ELSE GOTO (28) Date of first collection for this mobilization: 17 Growth and mobilizing factor(s) O yes O no IF (17) Growth and mobilizing factor(s):= yes THEN GOTO (18) G-CSF ELSE GOTO (26) Other therapy IF (17) Growth and mobilizing factor(s):= no AND HCT type:= AUTO THEN GOTO (24) Systemic therapy ELSE GOTO (26) Other therapy 18 G-CSF O yes O no ELSE GOTO (19) Pegylated G-CSF 19 Pegylated G-CSF O yes O no ELSE GOTO (20) GM-CSF 20 GM-CSF O yes O no ELSE GOTO (21) Plerixafor (Mozobil) 21 Plerixafor (Mozobil) O yes CIBMTR Form 2006 revision 4 (page 5 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O no ELSE GOTO (22) Other growth or mobilizing factor 22 Other growth or mobilizing factor O yes O no IF (22) Other growth or mobilizing factor:= yes THEN GOTO (23) Specify other growth or mobilizing factor: ELSE GOTO (26) Other therapy IF (22) Other growth or mobilizing factor:= no AND HCT type:= AUTO THEN GOTO (24) Systemic therapy ELSE GOTO (26) Other therapy 23 Specify other growth or mobilizing factor: ________________________ IF (23) Specify other growth or mobilizing factor: := EXISTS AND HCT type:= AUTO THEN GOTO (24) Systemic therapy ELSE GOTO (26) Other therapy 24 Systemic therapy (chemotherapy) (autologous only) O yes O no IF (24) Systemic therapy:= yes THEN GOTO (25) Anti-CD20 (rituximab, Rituxan) ELSE GOTO (26) Other therapy 25 Anti-CD20 (rituximab, Rituxan) (autologous only) O yes O no ELSE GOTO (26) Other therapy 26 Other therapy O yes O no IF (26) Other therapy:= yes THEN GOTO (27) Specify other therapy: ELSE GOTO (28) Date of first collection for this mobilization: 27 Specify other therapy: ________________________ ELSE GOTO (28) Date of first collection for this mobilization: Product Collection Questions: 28-42 If more than one type of HCT product is infused, each product type must be analyzed and reported separately. A series of collections should be considered a single product when they are all from the same donor and use the same collection method and technique (and mobilization, if appicable), even if the collections are performed on different days. 28 Date of first collection for this mobilization: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO (29) Was more than one collection required for this HCT? 29 Was more than one collection required for this HCT? O yes O no IF (29) Was more than one collection required for this HCT?:= yes THEN GOTO (30) Specify the number of subsequent days of collection in this episode: ELSE GOTO (31) Were anticoagulants added to the product during collection? Complete a separate CIBMTR form 2006 – HCT Infustion for each subsequent collection that was not part of this mobilization. 30 Specify the number of subsequent days of collection in this episode: ___ ___ ELSE GOTO (31) Were anticoagulants added to the product during collection? CIBMTR Form 2006 revision 4 (page 6 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 31 Were anticoagulants added to the product during collection? O yes O no IF (31) Were anticoagulants added to the product during collection?:= yes THEN GOTO (32) Acid citrate dextrose (ACD) ELSE GOTO (37) Were anticoagulants added to the product before freezing? Specify anticoagulant(s): 32 Acid citrate dextrose (ACD) O yes O no ELSE GOTO (33) Citrate phosphate dextrose (CPD) 33 Citrate phosphate dextrose (CPD) O yes O no ELSE GOTO (34) Heparin 34 Heparin O yes O no ELSE GOTO (35) Other anticoagulant 35 Other anticoagulant O yes O no IF (35) Other anticoagulant:= yes THEN GOTO (36) Specify other anticoagulant: ELSE GOTO (37) Were anticoagulants added to the product before freezing? 36 Specify other anticoagulant: ________________________ ELSE GOTO (37) Were anticoagulants added to the product before freezing? 37 Were anticoagulants added to the product before freezing? O yes O no IF (37) Were anticoagulants added to the product before freezing?:= yes THEN GOTO (38) Acid citrate dextrose (ACD) ELSE GOTO (43) Was this product collected off-site and shipped to your facility? Specify anticoagulant(s): 38 Acid citrate dextrose (ACD) O yes O no ELSE GOTO (39) Citrate phosphate dextrose (CPD) 39 Citrate phosphate dextrose (CPD) O yes O no ELSE GOTO (40) Heparin 40 Heparin O yes O no ELSE GOTO (41) Other anticoagulant 41 Other anticoagulant O yes O no IF (41) Other anticoagulant:= yes THEN GOTO (42) Specify other anticoagulant: ELSE GOTO (43) Was this product collected off-site and shipped to your facility? CIBMTR Form 2006 revision 4 (page 7 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 42 Specify other anticoagulant: ________________________ ELSE GOTO (43) Was this product collected off-site and shipped to your facility? Product Transport and Receipt Questions: 43-56 43 Was this product collected off-site and shipped to your facility? O yes O no IF (43) Was this product collected off-site and shipped to your facility?:= yes THEN GOTO (44) Date of receipt of product at your facility: ELSE GOTO (57) Was a fresh product received (e.g. not frozen)? 44 Date of receipt of product at your facility: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO (45) Time of receipt of product (24-hour clock): 45 Time of receipt of product (24-hour clock): ___ ___ - ___ ___ HH MM hour) ELSE GOTO Standard or daylight savings time (24 O standard time O daylight savings time ELSE GOTO (46) Specify the shipping environment of the product(s) 46 Specify the shipping environment of the product(s) O Frozen gel pack (refrigerator temperature) O Frozen cord blood unit(s) O Room temperature per transplant center request O Other shipping environment IF (46) Specify the shipping environment of the product(s):= Other shipping environment THEN GOTO (47) Specify other shipping environment: ELSE GOTO (57) Was a fresh product received (e.g. not frozen)? IF (46) Specify the shipping environment of the product(s):= Frozen gel pack AND Product type:= SCBU THEN GOTO (48) Was there any indication that the environment within the shipper was outside the expected temperature range for this product at any time during shipment? ELSE GOTO (57) Was a fresh product received (e.g. not frozen)? IF (46) Specify the shipping environment of the product(s):= Frozen cord blood unit(s) THEN GOTO (48) Was there any indication that the environment within the shipper was outside the expected temperature range for this product at any time during shipment? ELSE GOTO (57) Was a fresh product received (e.g. not frozen)? IF (46) Specify the shipping environment of the product(s):= Room temperature per transplant center request AND Product type:= SCBU THEN GOTO (48) Was there any indication that the environment within the shipper was outside the expected temperature range for this product at any time during shipment? ELSE GOTO (57) Was a fresh product received (e.g. not frozen)? 47 Specify other shipping environment: ________________________ IF (47) Specify other shipping environment: := EXISTS AND Product type:= SCBU THEN GOTO (48) Was there any indication that the environment within the shipper was outside the expected temperature range for this product at any time during shipment? ELSE GOTO (57) Was a fresh product received (e.g. not frozen)? 48 Was there any indication that the environment within the shipper was outside the expected temperature range for this product at any time during shipment? (Cord blood units only) O yes O no ELSE GOTO (49) Were the secondary containers (e.g., insulated shipping containers and unit cassette) intact when they arrived at your center? 49 Were the secondary containers (e.g., insulated shipping containers and unit cassette) intact when they arrived at your center? (Cord blood units only) CIBMTR Form 2006 revision 4 (page 8 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O yes O no ELSE GOTO (50) Was the cord blood unit stored at your center prior to thawing? 50 Was the cord blood unit stored at your center prior to thawing? O yes O no IF (50) Was the cord blood unit stored at your center prior to thawing?:= yes THEN GOTO (51) Specify the storage method used for the cord blood unit ELSE GOTO (54) Total nucleated cells: 51 Specify the storage method used for the cord blood unit O Electric freezer O Liquid nitrogen O Vapor phase ELSE GOTO (52) Temperature during storage 52 Temperature during storage O < -150° C O ≥ -150° C to < -135° C O ≥ -135° C to < -80° C O ≥ -80° C ELSE GOTO (53) Date storage started: 53 Date storage started: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO (54) Total nucleated cells: Report the total number of cells (not cells per kilogram) prior to cryopreservation: (Information provided for the unit by the cord blood bank). 54 Total nucleated ___ ___ ___ ● ___ ___ x ___ ___ cells: 10 ELSE GOTO TNC exponent (Includes nucleated red and nucleated white cells) (Cord blood units only) ELSE GOTO (55) CD34+ cells 55 CD34+ cells (cord blood units only) O Done O Not done IF (55) CD34+ cells:= Done THEN GOTO (56) Total number of CD34+ cells: ELSE GOTO (57) Was a fresh product received (e.g. not frozen)? 56 Total number of CD34+ cells: ELSE GOTO x 10 ___ ___ ___ ● ___ ___ x 10 ___ ___ IF x 10:= EXISTS AND (1) Specify donor:= NMDP_DNR_U THEN GOTO (57) Was a fresh product received (e.g. not frozen)? ELSE GOTO (59) Was the product thawed from a cryopreserved state prior to infusion? IF x 10:= EXISTS AND (1) Specify donor:= REL_CBU THEN GOTO (57) Was a fresh product received (e.g. not frozen)? ELSE GOTO (59) Was the product thawed from a cryopreserved state prior to infusion? Product Processing / Manipulation 57 Was a fresh product received (e.g. not frozen)? CIBMTR Form 2006 revision 4 (page 9 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. Questions: 57-108 CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ (NMDP products only) O Yes O No O not applicable, cord blood unit IF (57) Was a fresh product received (e.g. not frozen)?:= Yes THEN GOTO (58) Was the entire fresh product cryopreserved at your facility prior to infusion? ELSE GOTO (59) Was the product thawed from a cryopreserved state prior to infusion? 58 Was the entire fresh product cryopreserved at your facility prior to infusion? (NMDP products only) O yes O no ELSE GOTO (59) Was the product thawed from a cryopreserved state prior to infusion? 59 Was the product thawed from a cryopreserved state prior to infusion? O yes O no IF (59) Was the product thawed from a cryopreserved state prior to infusion?:= yes THEN GOTO (60) Was the entire product thawed? ELSE GOTO (71) Was the product manipulated prior to infusion? 60 Was the entire product thawed? O yes O no IF (60) Was the entire product thawed?:= no THEN GOTO (61) Was only a compartment of the bag thawed? ELSE GOTO (64) Date thawing process initiated: 61 Was only a compartment of the bag thawed? (Cord blood units only) O yes O no ELSE GOTO (62) Were there multiple product bags? 62 Were there multiple product bags? O yes O no IF (62) Were there multiple product bags?:= yes THEN GOTO (63) Specify number of bags thawed: ELSE GOTO (64) Date thawing process initiated: 63 Specify number of bags thawed: ___ ___ ELSE GOTO (64) Date thawing process initiated: 64 Date thawing process initiated: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO (65) Time at initiation of thaw (24-hour clock): 65 Time at initiation of thaw (24-hour clock): O standard time O daylight savings time ELSE GOTO (66) Time product ready for infusion or expansion (24-hour clock): ___ ___ - ___ ___ HH MM hour) ELSE GOTO Standard or daylight savings time 66 Time product ready for infusion or expansion (24-hour clock): (24 ___ ___ - ___ ___ HH MM hour) ELSE GOTO Standard or daylight savings time (24 O standard time O daylight savings time ELSE GOTO (67) Was the primary container (e.g., cord blood unit bag) intact upon thawing? 67 Was the primary container (e.g., cord blood unit bag) intact upon thawing? CIBMTR Form 2006 revision 4 (page 10 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O yes O no ELSE GOTO (68) What method was used to thaw the product? 68 What method was used to thaw the product? O Waterbath O Electric warmer O Other method IF (68) What method was used to thaw the product?:= Other method THEN GOTO (69) Specify other method: ELSE GOTO (70) Did any adverse events, incidents, or product complaints occur while preparing or thawing the product? 69 Specify other method: ________________________ ELSE GOTO (70) Did any adverse events, incidents, or product complaints occur while preparing or thawing the product? 70 Did any adverse events, incidents, or product complaints occur while preparing or thawing the product? O yes O no ELSE GOTO (71) Was the product manipulated prior to infusion? 71 Was the product manipulated prior to infusion? O yes O no IF (71) Was the product manipulated prior to infusion?:= yes THEN GOTO (72) Specify portion manipulated ELSE GOTO (158) Specify the timepoint in the product preparation phase that the product was analyzed IF (71) Was the product manipulated prior to infusion?:= no AND HCT type:= AUTO THEN GOTO (109) Were tumor cells detected in the recipient or autologous product prior to HCT? ELSE GOTO (158) Specify the timepoint in the product preparation phase that the product was analyzed 72 Specify portion manipulated O entire product O portion of product ELSE GOTO (73) Washed Specify all methods used to manipulate the product: 73 Washed O yes O no ELSE GOTO (74) Diluted 74 Diluted O yes O no ELSE GOTO (75) Buffy coat enriched 75 Buffy coat enriched (buffy coat preparation) O yes O no ELSE GOTO (76) B-cell reduced 76 B-cell reduced O yes O no ELSE GOTO (77) CD8 reduced 77 CD8 reduced O yes O no ELSE GOTO (78) Plasma reduced CIBMTR Form 2006 revision 4 (page 11 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 78 Plasma reduced (removal) O yes O no ELSE GOTO (79) RBC reduced 79 RBC reduced O yes O no ELSE GOTO (80) Cultured 80 Cultured (ex-vivo expansion) O yes O no ELSE GOTO (81) Genetic manipulation 81 Genetic manipulation (gene transfer / transduction) O yes O no ELSE GOTO (82) PUVA treated 82 PUVA treated O yes O no ELSE GOTO (83) CD34 enriched (CD34+ selection) 83 CD34 enriched (CD34+ selection) (CD34+ selection) O yes O no ELSE GOTO (84) CD133 enriched 84 CD133 enriched O yes O no ELSE GOTO (85) Monocyte enriched 85 Monocyte enriched O yes O no ELSE GOTO (86) Mononuclear cells enriched 86 Mononuclear cells enriched O yes O no ELSE GOTO (87) T-cell depletion 87 T-cell depletion O yes O no IF (87) T-cell depletion:= yes THEN GOTO (88) Antibody affinity column ELSE GOTO (94) Other cell manipulation Specify method: 88 Antibody affinity column O yes - Report the antibodies used for T-cell depletion at question 96 O no ELSE GOTO (89) Antibody coated plates 89 Antibody coated plates O yes - Report the antibodies used for T-cell depletion at question 96 CIBMTR Form 2006 revision 4 (page 12 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O no ELSE GOTO (90) Antibody coated plates and soybean lectin 90 Antibody coated plates and soybean lectin O yes - Report the antibodies used for T-cell depletion at question 96 O no ELSE GOTO (91) Antibody + toxin 91 Antibody + toxin O yes - Report the antibodies used for T-cell depletion at question 96 O no ELSE GOTO (92) Immunomagnetic beads 92 Immunomagnetic beads O yes - Report the antibodies used for T-cell depletion at question 96 O no ELSE GOTO (93) CD34 affinity column plus sheep red blood cell rosetting 93 CD34 affinity column plus sheep red blood cell rosetting O yes O no ELSE GOTO (94) Other cell manipulation 94 Other cell manipulation O yes O no IF (94) Other cell manipulation:= yes THEN GOTO (95) Specify other cell manipulation: ELSE GOTO (96) Were antibodies used during product manipulation? 95 Specify other cell manipulation: ________________________ ELSE GOTO (96) Were antibodies used during product manipulation? 96 Were antibodies used during product manipulation? O yes O no IF (96) Were antibodies used during product manipulation?:= yes THEN GOTO (97) Anti CD2 ELSE GOTO (109) Were tumor cells detected in the recipient or autologous product prior to HCT? Specify antibodies: 97 Anti CD2 O yes O no ELSE GOTO (98) Anti CD3 98 Anti CD3 O yes O no ELSE GOTO (99) Anti CD4 99 Anti CD4 O yes O no ELSE GOTO (100) Anti CD5 100 Anti CD5 O yes O no ELSE GOTO (101) Anti CD6 101 Anti CD6 O yes O no CIBMTR Form 2006 revision 4 (page 13 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO (102) Anti CD7 102 Anti CD7 O yes O no ELSE GOTO (103) Anti CD8 103 Anti CD8 O yes O no ELSE GOTO (104) Anti CD19 104 Anti CD19 O yes O no ELSE GOTO (105) a/ß antibody 105 a/ß antibody O yes O no ELSE GOTO (106) Anti CD52 106 Anti CD52 (Campath) O yes O no ELSE GOTO (107) Other antibody 107 Other antibody O yes O no IF (107) Other antibody:= yes THEN GOTO (108) Specify other antibody: ELSE GOTO (158) Specify the timepoint in the product preparation phase that the product was analyzed IF (107) Other antibody:= no AND HCT type:= AUTO THEN GOTO (109) Were tumor cells detected in the recipient or autologous product prior to HCT? ELSE GOTO (158) Specify the timepoint in the product preparation phase that the product was analyzed 108 Specify other antibody: ________________________ IF (108) Specify other antibody: := EXISTS AND HCT type:= AUTO THEN GOTO (109) Were tumor cells detected in the recipient or autologous product prior to HCT? ELSE GOTO (158) Specify the timepoint in the product preparation phase that the product was analyzed Autologous Products Only Questions: 109-157 The following section refers to autologous products only, including autologous cord blood; if this is not an autologous HCT, continue with the Product Analysis section at question 158. 109 Were tumor cells detected in the recipient or autologous product prior to HCT? O yes O no IF (109) Were tumor cells detected in the recipient or autologous product prior to HCT?:= yes THEN GOTO (110) Routine histopathology ELSE GOTO (136) Was the product treated to remove malignant cells (purged)? Specify tumor cell detection method used and site(s) of tumor cells: 110 Routine histopathology O yes O no IF (110) Routine histopathology:= yes THEN GOTO (111) Circulating blood cells CIBMTR Form 2006 revision 4 (page 14 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO (114) Polymerase chain reaction (PCR) Specify site(s): 111 Circulating blood cells O Yes O No O Not done ELSE GOTO (112) Bone marrow 112 Bone marrow (in the interval between last systemic therapy and collection) O Yes O No O Not done ELSE GOTO (113) Collected cells 113 Collected cells (before purging) O Yes O No O Not done ELSE GOTO (114) Polymerase chain reaction (PCR) 114 Polymerase chain reaction (PCR) O yes O no IF (114) Polymerase chain reaction (PCR):= yes THEN GOTO (115) Circulating blood cells ELSE GOTO (118) Other molecular technique Specify site(s): 115 Circulating blood cells O Yes O No O Not done ELSE GOTO (116) Bone marrow 116 Bone marrow (in the interval between last systemic therapy and collection) O Yes O No O Not done ELSE GOTO (117) Collected cells 117 Collected cells (before purging) O Yes O No O Not done ELSE GOTO (118) Other molecular technique 118 Other molecular technique O yes O no IF (118) Other molecular technique:= yes THEN GOTO (119) Specify method: ELSE GOTO (123) Immunohistochemistry 119 Specify method: ________________________ ELSE GOTO (120) Circulating blood cells Specify site(s): 120 Circulating blood cells O Yes CIBMTR Form 2006 revision 4 (page 15 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O No O Not done ELSE GOTO (121) Bone marrow 121 Bone marrow (in the interval between last systemic therapy and collection) O Yes O No O Not done ELSE GOTO (122) Collected cells 122 Collected cells (before purging) O Yes O No O Not done ELSE GOTO (123) Immunohistochemistry 123 Immunohistochemistry O yes O no IF (123) Immunohistochemistry:= yes THEN GOTO (124) Circulating blood cells ELSE GOTO (127) Cell culture technique Specify site(s): 124 Circulating blood cells O Yes O No O Not done ELSE GOTO (125) Bone marrow 125 Bone marrow (in the interval between last systemic therapy and collection) O Yes O No O Not done ELSE GOTO (126) Collected cells 126 Collected cells (before purging) O Yes O No O Not done ELSE GOTO (127) Cell culture technique 127 Cell culture technique O yes O no IF (127) Cell culture technique:= yes THEN GOTO (128) Circulating blood cells ELSE GOTO (131) Other technique Specify site(s): 128 Circulating blood cells O Yes O No O Not done ELSE GOTO (129) Bone marrow 129 Bone marrow (in the interval between last systemic therapy and collection) O Yes O No CIBMTR Form 2006 revision 4 (page 16 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O Not done ELSE GOTO (130) Collected cells 130 Collected cells (before purging) O Yes O No O Not done ELSE GOTO (131) Other technique 131 Other technique O yes O no IF (131) Other technique:= yes THEN GOTO (132) Specify: ELSE GOTO (136) Was the product treated to remove malignant cells (purged)? 132 Specify: ________________________ ELSE GOTO (133) Circulating blood cells Specify site(s): 133 Circulating blood cells O Yes O No O Not done ELSE GOTO (134) Bone marrow 134 Bone marrow (in the interval between last systemic therapy and collection) O Yes O No O Not done ELSE GOTO (135) Collected cells 135 Collected cells (before purging) O Yes O No O Not done ELSE GOTO (136) Was the product treated to remove malignant cells (purged)? 136 Was the product treated to remove malignant cells (purged)? O yes O no IF (136) Was the product treated to remove malignant cells (purged)?:= yes THEN GOTO (137) Monoclonal antibody ELSE GOTO (158) Specify the timepoint in the product preparation phase that the product was analyzed Specify method(s) used: 137 Monoclonal antibody O yes O no IF (137) Monoclonal antibody:= yes THEN GOTO (138) Specify monoclonal antibody: ELSE GOTO (139) 4-hydroperoxycyclophosphamide (4HC) 138 Specify monoclonal antibody: ________________________ ELSE GOTO (139) 4-hydroperoxycyclophosphamide (4HC) 139 4-hydroperoxycyclophosphamide (4HC) O yes O no ELSE GOTO (140) Mafosfamide CIBMTR Form 2006 revision 4 (page 17 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 140 Mafosfamide O yes O no ELSE GOTO (141) Other drug 141 Other drug O yes O no IF (141) Other drug:= no THEN GOTO (142) Specify other drug: ELSE GOTO (143) Elutriation 142 Specify other drug: ________________________ ELSE GOTO (143) Elutriation 143 Elutriation O yes O no ELSE GOTO (144) Immunomagnetic column 144 Immunomagnetic column O yes O no ELSE GOTO (145) Toxin 145 Toxin O yes O no IF (145) Toxin:= yes THEN GOTO (146) Specify toxin: ELSE GOTO (147) CD34 selection 146 Specify toxin: ________________________ ELSE GOTO (147) CD34 selection 147 CD34 selection (other than preparation of mononuclear fraction) O yes O no IF (147) CD34 selection:= yes THEN GOTO (148) Specify method: ELSE GOTO (149) Other method 148 Specify method: ________________________ ELSE GOTO (149) Other method 149 Other method O yes O no IF (149) Other method:= yes THEN GOTO (150) Specify: ELSE GOTO (151) Routine histopathology 150 Specify: ________________________ ELSE GOTO (151) Routine histopathology Specify if tumor cells were detected in the graft after purging by each method used: 151 Routine histopathology O Yes O No O Not done ELSE GOTO (152) Polymerase chain reaction (PCR) 152 Polymerase chain reaction (PCR) CIBMTR Form 2006 revision 4 (page 18 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O Yes O No O Not done ELSE GOTO (153) Other molecular technique 153 Other molecular technique O Yes O No O Not done ELSE GOTO (154) Immunohistochemistry 154 Immunohistochemistry O Yes O No O Not done ELSE GOTO (155) Cell culture technique 155 Cell culture technique O Yes O No O Not done ELSE GOTO (156) Other 156 Other O Yes O No O Not done IF (156) Other:= Yes THEN GOTO (157) Specify: ELSE GOTO (158) Specify the timepoint in the product preparation phase that the product was analyzed 157 Specify: ________________________ ELSE GOTO (158) Specify the timepoint in the product preparation phase that the product was analyzed Product Analysis (All Products) Product Analysis Questions: 158-195 Questions: 158 - 195 158 Specify the timepoint in the product preparation phase that the product was analyzed O Product arrival O Pre-cryopreservation O Post-thaw O At infusion ELSE GOTO (159) Date of product analysis: 159 Date of product analysis: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO (160) Total volume of product plus additives: 160 Total volume of product plus additives: ___ ___ ___ ___ ___ ● ___ ELSE GOTO (161) Total nucleated cells (TNC) In this section, report the total number of cells (not cells per kilogram) not corrected for viability 161 Total nucleated cells (TNC) (Includes nucleated red and nucleated white cells) O Done O Not done IF (161) Total nucleated cells (TNC):= Done THEN GOTO (162) Total nucleated cells: ELSE GOTO (163) Nucleated white blood cells CIBMTR Form 2006 revision 4 (page 19 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 162 Total nucleated cells: ___ ___ ___ ● ___ ___ ELSE GOTO Nucleated cells exponent x 10 ___ ___ ELSE GOTO (163) Nucleated white blood cells 163 Nucleated white blood cells O Done O Not done IF (163) Nucleated white blood cells := Done THEN GOTO (164) Total number of nucleated white blood cells: ELSE GOTO (165) Mononuclear cells 164 Total number of nucleated white blood cells: ELSE GOTO Nucleated wbc exponent ___ ___ ___ ● ___ ___ x 10 ___ ___ ELSE GOTO (165) Mononuclear cells 165 Mononuclear cells O Done O Not done IF (165) Mononuclear cells := Done THEN GOTO (166) Total number of mononuclear cells: ELSE GOTO (167) Nucleated red blood cells 166 Total number of mononuclear ___ ___ ___ ● ___ ___ cells: ELSE GOTO Mononuclear cells exponent x 10 ___ ___ ELSE GOTO (167) Nucleated red blood cells 167 Nucleated red blood cells O Done O Not done IF (167) Nucleated red blood cells := Done THEN GOTO (168) Total number of nucleated red blood cells: ELSE GOTO (169) CD34+ cells 168 Total number of nucleated red blood cells: ELSE GOTO RBC exponent ___ ___ ___ ● ___ ___ x 10 ___ ___ ELSE GOTO (169) CD34+ cells 169 CD34+ cells O Done O Not done IF (169) CD34+ cells:= Done THEN GOTO (170) Total number of CD34+ cells: ELSE GOTO (171) CD3+ cells 170 Total number of CD34+ cells: ___ ___ ___ ● ___ ___ ELSE GOTO CD34+ cells exponent x 10 ___ ___ ELSE GOTO (171) CD3+ cells 171 CD3+ cells O Done O Not done IF (171) CD3+ cells := Done THEN GOTO (172) Total number of CD3+ cells: ELSE GOTO (173) CD3+CD4+ cells 172 Total number of CD3+ cells: ___ ___ ___ ● ___ ___ ELSE GOTO CD3+ cells exponent 173 CD3+CD4+ cells O Done O Not done CIBMTR Form 2006 revision 4 (page 20 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. x 10 ___ ___ ELSE GOTO (173) CD3+CD4+ cells CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ IF (173) CD3+CD4+ cells := Done THEN GOTO (174) Total number of CD3+CD4+ cells: ELSE GOTO (175) CD3+CD8+ cells 174 Total number of CD3+CD4+ cells: ___ ___ ___ ● ___ ___ ELSE GOTO CD4+ cells exponent x 10 ___ ___ ELSE GOTO (175) CD3+CD8+ cells 175 CD3+CD8+ cells O Done O Not done IF (175) CD3+CD8+ cells := Done THEN GOTO (176) Total number of CD3+CD8+ cells: ELSE GOTO (177) Viability of cells 176 Total number of CD3+CD8+ cells: ___ ___ ___ ● ___ ___ ELSE GOTO CD8+ cells exponent x 10 ___ ___ ELSE GOTO (177) Viability of cells 177 Viability of cells O Done O Not done IF (177) Viability of cells := Done THEN GOTO (178) Viability percent ELSE GOTO (187) Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? IF (177) Viability of cells := Not done AND Product type:= SCBU THEN GOTO (181) Were the colony-forming units (CFU) assessed after thawing? ELSE GOTO (187) Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? 178 Viability of cells: ___ ___ ___ ___ ● ___ % ELSE GOTO (179) Method of testing cell viability 179 Method of testing cell viability O 7-AAD O Propidium iodide O Trypan blue O Other method IF (179) Method of testing cell viability:= Other method THEN GOTO (180) Specify other method: ELSE GOTO (181) Were the colony-forming units (CFU) assessed after thawing? 180 Specify other method: ________________________ IF (180) Specify other method: := EXISTS AND Product type:= SCBU THEN GOTO (181) Were the colony-forming units (CFU) assessed after thawing? ELSE GOTO (187) Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? 181 Were the colony-forming units (CFU) assessed after thawing? (Cord blood units only) O yes O no IF (181) Were the colony-forming units (CFU) assessed after thawing?:= yes THEN GOTO (182) Was there growth? ELSE GOTO (187) Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? 182 Was there growth? O yes O no ELSE GOTO (183) Total CFU-GM 183 Total CFU-GM CIBMTR Form 2006 revision 4 (page 21 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O Done O Not done IF (183) Total CFU-GM:= Done THEN GOTO (184) Total CFU-GM value ELSE GOTO (185) Total BFU-E 184 Total CFU-GM: ___ ___ ___ ___ ● ___ ELSE GOTO CFU-GM exponent x 10 ___ ___ ELSE GOTO (185) Total BFU-E 185 Total BFU-E O Done O Not done IF (185) Total BFU-E:= Done THEN GOTO (186) Total BFU-E value ELSE GOTO (187) Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? 186 Total ___ ___ ___ ● ___ ___ BFU-E: ELSE GOTO BFU-E exponent x 10 ___ ___ ELSE GOTO (187) Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? 187 Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? (complete for all cell products) O yes O no IF (187) Were cultures performed before infusion to test the product(s) for bacterial or fungal infection?:= yes THEN GOTO (188) Specify results ELSE GOTO (196) Date of this product infusion: 188 Specify results O Positive O Negative O Unknown ELSE GOTO (189) Specify organism code 1 Specify organism(s): 189 O 121 Acinetobacter O 122 Actinomyces O 123 Bacillus O 124 Bacteroides(gracillis,uniformis,vulgaris, other species) O 125 Bordetella pertussis (whooping cough) O 126 Borrelia (lyme disease) O 127 Branhamella or Moraxella catarrhalis(other species) O 128 Campylobacter (all species) O 129 Capnocytophaga O 171 Chlamydia pneumoniae O 172 Other chlamydia, specify O 113 Chlamydia, NOS O 130 Citrobacter (freundii, other species) O 131 Clostridium (all species except difficile) O 132 Clostridium difficile O 173 Corynebacterium jeikeium O 133 Corynebacterium (all non-diptheria species) O 101 Coxiella O 134 Enterobacter O 177 Enterococcus, vancomycin resistant(VRE) O 135 Enterococcus(all species) O 136 Escherichia (also E.coli) O 137 Flavimonas oryzihabitans O 138 Flavobacterium CIBMTR Form 2006 revision 4 (page 22 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 139 Fusobacterium O 144 Haemophilus(all species, including influenzae) O 145 Helicobacter pylori O 146 Klebsiella O 147 Lactobacillus(bulgaricus, acidophilus, other species) O 102 Legionella O 103 Leptospira O 148 Leptorichia buccalis O 149 Leuconostoc(all species) O 104 Listeria O 150 Methylobacterium O 151 Micrococcus, NOS O 112 Mycobacterium avium-intracellulare(MAC, MAI) O 174 Mycobacterium species (cheloneae, fortuitum, haemophilum,kansasii, mucogenicum) O 110 Mycobacterium tuberculosis (tuberculosis,Koch bacillus) O 175 Other mycobacterium, specify O 176 Mycobacterium, NOS O 105 Mycoplasma O 152 Neisseria (gonorrhoea, meningitidis, other species) O 106 Nocardia O 153 Pasteurella multocida O 154 Propionibacterium (acnes, avidum, granulosum, other species) O 155 Proteus O 156 Pseudomonas (all species except cepacia & maltophilia) O 157 Pseudomonas or Burkholderia cepacia O 158 Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia O 159 Rhodococcus O 107 Rickettsia O 160 Salmonella (all species) O 161 Serratia marcescens O 162 Shigella O 163 Staphylococcus, coagulase negative(not aureus) O 164 Staphylococcus aureus O 165 Staphylococcus, NOS O 166 Stomatococcus mucilaginosis O 167 Streptococcus (all species except Enterococcus) O 178 Streptococcus pneumoniae O 168 Treponema ( syphilis ) O 169 Vibrio (all species) O 197 Multiple bacteria at a single site, specify bacterial codes O 198 Other bacteria, specify O 501 Suspected atypical bacterial infection O 502 Suspected bacterial infection O 200 Candida, NOS O 201 Candida albicans O 206 Candida guillermondi O 202 Candida krusei O 207 Candida lusitaniae O 203 Candida parapsilosis O 204 Candida tropicalis O 205 Candida (Torulopsis) glabrata O 209 Other Candida, specify O 210 Aspergillus, NOS O 211 Aspergillus flavus O 212 Aspergillus fumigatus O 213 Aspergillus niger O 219 Other Aspergillus, specify O 220 Cryptococcus species O 230 Fusarium species O 261 Histoplasmosis O 240 Zygomycetes, NOS O 241 Mucormycosis O 242 Rhizopus O 250 Yeast, NOS CIBMTR Form 2006 revision 4 (page 23 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 259 Other fungus, specify O 260 Pneumocystis (PCP / PJP) O 503 Suspected fungal infection IF (189) Specify organism code 1:= 198 Other bacteria, specify THEN GOTO (195) Specify organism: ELSE GOTO (190) Specify organism code 2 IF (189) Specify organism code 1:= 209 Other Candida, specify THEN GOTO (195) Specify organism: ELSE GOTO (190) Specify organism code 2 IF (189) Specify organism code 1:= 219 Other Aspergillus, specify THEN GOTO (195) Specify organism: ELSE GOTO (190) Specify organism code 2 IF (189) Specify organism code 1:= 259 Other fungus, specify THEN GOTO (195) Specify organism: ELSE GOTO (190) Specify organism code 2 190 O 121 Acinetobacter O 122 Actinomyces O 123 Bacillus O 124 Bacteroides(gracillis,uniformis,vulgaris, other species) O 125 Bordetella pertussis (whooping cough) O 126 Borrelia (lyme disease) O 127 Branhamella or Moraxella catarrhalis(other species) O 128 Campylobacter (all species) O 129 Capnocytophaga O 171 Chlamydia pneumoniae O 172 Other chlamydia, specify O 113 Chlamydia, NOS O 130 Citrobacter (freundii, other species) O 131 Clostridium (all species except difficile) O 132 Clostridium difficile O 173 Corynebacterium jeikeium O 133 Corynebacterium (all non-diptheria species) O 101 Coxiella O 134 Enterobacter O 177 Enterococcus, vancomycin resistant(VRE) O 135 Enterococcus(all species) O 136 Escherichia (also E.coli) O 137 Flavimonas oryzihabitans O 138 Flavobacterium O 139 Fusobacterium O 144 Haemophilus(all species, including influenzae) O 145 Helicobacter pylori O 146 Klebsiella O 147 Lactobacillus(bulgaricus, acidophilus, other species) O 102 Legionella O 103 Leptospira O 148 Leptorichia buccalis O 149 Leuconostoc(all species) O 104 Listeria O 150 Methylobacterium O 151 Micrococcus, NOS O 112 Mycobacterium avium-intracellulare(MAC, MAI) O 174 Mycobacterium species (cheloneae, fortuitum, haemophilum,kansasii, mucogenicum) O 110 Mycobacterium tuberculosis (tuberculosis,Koch bacillus) O 175 Other mycobacterium, specify O 176 Mycobacterium, NOS O 105 Mycoplasma O 152 Neisseria (gonorrhoea, meningitidis, other species) O 106 Nocardia O 153 Pasteurella multocida O 154 Propionibacterium (acnes, avidum, granulosum, other species) O 155 Proteus CIBMTR Form 2006 revision 4 (page 24 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 156 Pseudomonas (all species except cepacia & maltophilia) O 157 Pseudomonas or Burkholderia cepacia O 158 Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia O 159 Rhodococcus O 107 Rickettsia O 160 Salmonella (all species) O 161 Serratia marcescens O 162 Shigella O 163 Staphylococcus, coagulase negative(not aureus) O 164 Staphylococcus aureus O 165 Staphylococcus, NOS O 166 Stomatococcus mucilaginosis O 167 Streptococcus (all species except Enterococcus) O 178 Streptococcus pneumoniae O 168 Treponema ( syphilis ) O 169 Vibrio (all species) O 197 Multiple bacteria at a single site, specify bacterial codes O 198 Other bacteria, specify O 501 Suspected atypical bacterial infection O 502 Suspected bacterial infection O 200 Candida, NOS O 201 Candida albicans O 206 Candida guillermondi O 202 Candida krusei O 207 Candida lusitaniae O 203 Candida parapsilosis O 204 Candida tropicalis O 205 Candida (Torulopsis) glabrata O 209 Other Candida, specify O 210 Aspergillus, NOS O 211 Aspergillus flavus O 212 Aspergillus fumigatus O 213 Aspergillus niger O 219 Other Aspergillus, specify O 220 Cryptococcus species O 230 Fusarium species O 261 Histoplasmosis O 240 Zygomycetes, NOS O 241 Mucormycosis O 242 Rhizopus O 250 Yeast, NOS O 259 Other fungus, specify O 260 Pneumocystis (PCP / PJP) O 503 Suspected fungal infection IF (190) Specify organism code 2:= 198 Other bacteria, specify THEN GOTO (195) Specify organism: ELSE GOTO (191) Specify organism code 3 IF (190) Specify organism code 2:= 209 Other Candida, specify THEN GOTO (195) Specify organism: ELSE GOTO (191) Specify organism code 3 IF (190) Specify organism code 2:= 219 Other Aspergillus, specify THEN GOTO (195) Specify organism: ELSE GOTO (191) Specify organism code 3 IF (190) Specify organism code 2:= 259 Other fungus, specify THEN GOTO (195) Specify organism: ELSE GOTO (191) Specify organism code 3 191 O 121 Acinetobacter O 122 Actinomyces O 123 Bacillus O 124 Bacteroides(gracillis,uniformis,vulgaris, other species) O 125 Bordetella pertussis (whooping cough) O 126 Borrelia (lyme disease) CIBMTR Form 2006 revision 4 (page 25 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 127 Branhamella or Moraxella catarrhalis(other species) O 128 Campylobacter (all species) O 129 Capnocytophaga O 171 Chlamydia pneumoniae O 172 Other chlamydia, specify O 113 Chlamydia, NOS O 130 Citrobacter (freundii, other species) O 131 Clostridium (all species except difficile) O 132 Clostridium difficile O 173 Corynebacterium jeikeium O 133 Corynebacterium (all non-diptheria species) O 101 Coxiella O 134 Enterobacter O 177 Enterococcus, vancomycin resistant(VRE) O 135 Enterococcus(all species) O 136 Escherichia (also E.coli) O 137 Flavimonas oryzihabitans O 138 Flavobacterium O 139 Fusobacterium O 144 Haemophilus(all species, including influenzae) O 145 Helicobacter pylori O 146 Klebsiella O 147 Lactobacillus(bulgaricus, acidophilus, other species) O 102 Legionella O 103 Leptospira O 148 Leptorichia buccalis O 149 Leuconostoc(all species) O 104 Listeria O 150 Methylobacterium O 151 Micrococcus, NOS O 112 Mycobacterium avium-intracellulare(MAC, MAI) O 174 Mycobacterium species (cheloneae, fortuitum, haemophilum,kansasii, mucogenicum) O 110 Mycobacterium tuberculosis (tuberculosis,Koch bacillus) O 175 Other mycobacterium, specify O 176 Mycobacterium, NOS O 105 Mycoplasma O 152 Neisseria (gonorrhoea, meningitidis, other species) O 106 Nocardia O 153 Pasteurella multocida O 154 Propionibacterium (acnes, avidum, granulosum, other species) O 155 Proteus O 156 Pseudomonas (all species except cepacia & maltophilia) O 157 Pseudomonas or Burkholderia cepacia O 158 Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia O 159 Rhodococcus O 107 Rickettsia O 160 Salmonella (all species) O 161 Serratia marcescens O 162 Shigella O 163 Staphylococcus, coagulase negative(not aureus) O 164 Staphylococcus aureus O 165 Staphylococcus, NOS O 166 Stomatococcus mucilaginosis O 167 Streptococcus (all species except Enterococcus) O 178 Streptococcus pneumoniae O 168 Treponema ( syphilis ) O 169 Vibrio (all species) O 197 Multiple bacteria at a single site, specify bacterial codes O 198 Other bacteria, specify O 501 Suspected atypical bacterial infection O 502 Suspected bacterial infection O 200 Candida, NOS O 201 Candida albicans O 206 Candida guillermondi CIBMTR Form 2006 revision 4 (page 26 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 202 Candida krusei O 207 Candida lusitaniae O 203 Candida parapsilosis O 204 Candida tropicalis O 205 Candida (Torulopsis) glabrata O 209 Other Candida, specify O 210 Aspergillus, NOS O 211 Aspergillus flavus O 212 Aspergillus fumigatus O 213 Aspergillus niger O 219 Other Aspergillus, specify O 220 Cryptococcus species O 230 Fusarium species O 261 Histoplasmosis O 240 Zygomycetes, NOS O 241 Mucormycosis O 242 Rhizopus O 250 Yeast, NOS O 259 Other fungus, specify O 260 Pneumocystis (PCP / PJP) O 503 Suspected fungal infection IF (191) Specify organism code 3:= 198 Other bacteria, specify THEN GOTO (195) Specify organism: ELSE GOTO (192) Specify organism code 4 IF (191) Specify organism code 3:= 209 Other Candida, specify THEN GOTO (195) Specify organism: ELSE GOTO (192) Specify organism code 4 IF (191) Specify organism code 3:= 219 Other Aspergillus, specify THEN GOTO (195) Specify organism: ELSE GOTO (192) Specify organism code 4 IF (191) Specify organism code 3:= 259 Other fungus, specify THEN GOTO (195) Specify organism: ELSE GOTO (192) Specify organism code 4 192 O 121 Acinetobacter O 122 Actinomyces O 123 Bacillus O 124 Bacteroides(gracillis,uniformis,vulgaris, other species) O 125 Bordetella pertussis (whooping cough) O 126 Borrelia (lyme disease) O 127 Branhamella or Moraxella catarrhalis(other species) O 128 Campylobacter (all species) O 129 Capnocytophaga O 171 Chlamydia pneumoniae O 172 Other chlamydia, specify O 113 Chlamydia, NOS O 130 Citrobacter (freundii, other species) O 131 Clostridium (all species except difficile) O 132 Clostridium difficile O 173 Corynebacterium jeikeium O 133 Corynebacterium (all non-diptheria species) O 101 Coxiella O 134 Enterobacter O 177 Enterococcus, vancomycin resistant(VRE) O 135 Enterococcus(all species) O 136 Escherichia (also E.coli) O 137 Flavimonas oryzihabitans O 138 Flavobacterium O 139 Fusobacterium O 144 Haemophilus(all species, including influenzae) O 145 Helicobacter pylori O 146 Klebsiella O 147 Lactobacillus(bulgaricus, acidophilus, other species) CIBMTR Form 2006 revision 4 (page 27 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 102 Legionella O 103 Leptospira O 148 Leptorichia buccalis O 149 Leuconostoc(all species) O 104 Listeria O 150 Methylobacterium O 151 Micrococcus, NOS O 112 Mycobacterium avium-intracellulare(MAC, MAI) O 174 Mycobacterium species (cheloneae, fortuitum, haemophilum,kansasii, mucogenicum) O 110 Mycobacterium tuberculosis (tuberculosis,Koch bacillus) O 175 Other mycobacterium, specify O 176 Mycobacterium, NOS O 105 Mycoplasma O 152 Neisseria (gonorrhoea, meningitidis, other species) O 106 Nocardia O 153 Pasteurella multocida O 154 Propionibacterium (acnes, avidum, granulosum, other species) O 155 Proteus O 156 Pseudomonas (all species except cepacia & maltophilia) O 157 Pseudomonas or Burkholderia cepacia O 158 Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia O 159 Rhodococcus O 107 Rickettsia O 160 Salmonella (all species) O 161 Serratia marcescens O 162 Shigella O 163 Staphylococcus, coagulase negative(not aureus) O 164 Staphylococcus aureus O 165 Staphylococcus, NOS O 166 Stomatococcus mucilaginosis O 167 Streptococcus (all species except Enterococcus) O 178 Streptococcus pneumoniae O 168 Treponema ( syphilis ) O 169 Vibrio (all species) O 197 Multiple bacteria at a single site, specify bacterial codes O 198 Other bacteria, specify O 501 Suspected atypical bacterial infection O 502 Suspected bacterial infection O 200 Candida, NOS O 201 Candida albicans O 206 Candida guillermondi O 202 Candida krusei O 207 Candida lusitaniae O 203 Candida parapsilosis O 204 Candida tropicalis O 205 Candida (Torulopsis) glabrata O 209 Other Candida, specify O 210 Aspergillus, NOS O 211 Aspergillus flavus O 212 Aspergillus fumigatus O 213 Aspergillus niger O 219 Other Aspergillus, specify O 220 Cryptococcus species O 230 Fusarium species O 261 Histoplasmosis O 240 Zygomycetes, NOS O 241 Mucormycosis O 242 Rhizopus O 250 Yeast, NOS O 259 Other fungus, specify O 260 Pneumocystis (PCP / PJP) O 503 Suspected fungal infection IF (192) Specify organism code 4:= 198 Other bacteria, specify THEN GOTO (195) Specify organism: CIBMTR Form 2006 revision 4 (page 28 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO (193) Specify organism code 5 IF (192) Specify organism code 4:= 209 Other Candida, specify THEN GOTO (195) Specify organism: ELSE GOTO (193) Specify organism code 5 IF (192) Specify organism code 4:= 219 Other Aspergillus, specify THEN GOTO (195) Specify organism: ELSE GOTO (193) Specify organism code 5 IF (192) Specify organism code 4:= 259 Other fungus, specify THEN GOTO (195) Specify organism: ELSE GOTO (193) Specify organism code 5 193 O 121 Acinetobacter O 122 Actinomyces O 123 Bacillus O 124 Bacteroides(gracillis,uniformis,vulgaris, other species) O 125 Bordetella pertussis (whooping cough) O 126 Borrelia (lyme disease) O 127 Branhamella or Moraxella catarrhalis(other species) O 128 Campylobacter (all species) O 129 Capnocytophaga O 171 Chlamydia pneumoniae O 172 Other chlamydia, specify O 113 Chlamydia, NOS O 130 Citrobacter (freundii, other species) O 131 Clostridium (all species except difficile) O 132 Clostridium difficile O 173 Corynebacterium jeikeium O 133 Corynebacterium (all non-diptheria species) O 101 Coxiella O 134 Enterobacter O 177 Enterococcus, vancomycin resistant(VRE) O 135 Enterococcus(all species) O 136 Escherichia (also E.coli) O 137 Flavimonas oryzihabitans O 138 Flavobacterium O 139 Fusobacterium O 144 Haemophilus(all species, including influenzae) O 145 Helicobacter pylori O 146 Klebsiella O 147 Lactobacillus(bulgaricus, acidophilus, other species) O 102 Legionella O 103 Leptospira O 148 Leptorichia buccalis O 149 Leuconostoc(all species) O 104 Listeria O 150 Methylobacterium O 151 Micrococcus, NOS O 112 Mycobacterium avium-intracellulare(MAC, MAI) O 174 Mycobacterium species (cheloneae, fortuitum, haemophilum,kansasii, mucogenicum) O 110 Mycobacterium tuberculosis (tuberculosis,Koch bacillus) O 175 Other mycobacterium, specify O 176 Mycobacterium, NOS O 105 Mycoplasma O 152 Neisseria (gonorrhoea, meningitidis, other species) O 106 Nocardia O 153 Pasteurella multocida O 154 Propionibacterium (acnes, avidum, granulosum, other species) O 155 Proteus O 156 Pseudomonas (all species except cepacia & maltophilia) O 157 Pseudomonas or Burkholderia cepacia O 158 Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia O 159 Rhodococcus O 107 Rickettsia CIBMTR Form 2006 revision 4 (page 29 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 160 Salmonella (all species) O 161 Serratia marcescens O 162 Shigella O 163 Staphylococcus, coagulase negative(not aureus) O 164 Staphylococcus aureus O 165 Staphylococcus, NOS O 166 Stomatococcus mucilaginosis O 167 Streptococcus (all species except Enterococcus) O 178 Streptococcus pneumoniae O 168 Treponema ( syphilis ) O 169 Vibrio (all species) O 197 Multiple bacteria at a single site, specify bacterial codes O 198 Other bacteria, specify O 501 Suspected atypical bacterial infection O 502 Suspected bacterial infection O 200 Candida, NOS O 201 Candida albicans O 206 Candida guillermondi O 202 Candida krusei O 207 Candida lusitaniae O 203 Candida parapsilosis O 204 Candida tropicalis O 205 Candida (Torulopsis) glabrata O 209 Other Candida, specify O 210 Aspergillus, NOS O 211 Aspergillus flavus O 212 Aspergillus fumigatus O 213 Aspergillus niger O 219 Other Aspergillus, specify O 220 Cryptococcus species O 230 Fusarium species O 261 Histoplasmosis O 240 Zygomycetes, NOS O 241 Mucormycosis O 242 Rhizopus O 250 Yeast, NOS O 259 Other fungus, specify O 260 Pneumocystis (PCP / PJP) O 503 Suspected fungal infection IF (193) Specify organism code 5:= 198 Other bacteria, specify THEN GOTO (195) Specify organism: ELSE GOTO (194) Specify organism code 6 IF (193) Specify organism code 5:= 209 Other Candida, specify THEN GOTO (195) Specify organism: ELSE GOTO (194) Specify organism code 6 IF (193) Specify organism code 5:= 219 Other Aspergillus, specify THEN GOTO (195) Specify organism: ELSE GOTO (194) Specify organism code 6 IF (193) Specify organism code 5:= 259 Other fungus, specify THEN GOTO (195) Specify organism: ELSE GOTO (194) Specify organism code 6 194 O 121 Acinetobacter O 122 Actinomyces O 123 Bacillus O 124 Bacteroides(gracillis,uniformis,vulgaris, other species) O 125 Bordetella pertussis (whooping cough) O 126 Borrelia (lyme disease) O 127 Branhamella or Moraxella catarrhalis(other species) O 128 Campylobacter (all species) O 129 Capnocytophaga O 171 Chlamydia pneumoniae O 172 Other chlamydia, specify CIBMTR Form 2006 revision 4 (page 30 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 113 Chlamydia, NOS O 130 Citrobacter (freundii, other species) O 131 Clostridium (all species except difficile) O 132 Clostridium difficile O 173 Corynebacterium jeikeium O 133 Corynebacterium (all non-diptheria species) O 101 Coxiella O 134 Enterobacter O 177 Enterococcus, vancomycin resistant(VRE) O 135 Enterococcus(all species) O 136 Escherichia (also E.coli) O 137 Flavimonas oryzihabitans O 138 Flavobacterium O 139 Fusobacterium O 144 Haemophilus(all species, including influenzae) O 145 Helicobacter pylori O 146 Klebsiella O 147 Lactobacillus(bulgaricus, acidophilus, other species) O 102 Legionella O 103 Leptospira O 148 Leptorichia buccalis O 149 Leuconostoc(all species) O 104 Listeria O 150 Methylobacterium O 151 Micrococcus, NOS O 112 Mycobacterium avium-intracellulare(MAC, MAI) O 174 Mycobacterium species (cheloneae, fortuitum, haemophilum,kansasii, mucogenicum) O 110 Mycobacterium tuberculosis (tuberculosis,Koch bacillus) O 175 Other mycobacterium, specify O 176 Mycobacterium, NOS O 105 Mycoplasma O 152 Neisseria (gonorrhoea, meningitidis, other species) O 106 Nocardia O 153 Pasteurella multocida O 154 Propionibacterium (acnes, avidum, granulosum, other species) O 155 Proteus O 156 Pseudomonas (all species except cepacia & maltophilia) O 157 Pseudomonas or Burkholderia cepacia O 158 Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia O 159 Rhodococcus O 107 Rickettsia O 160 Salmonella (all species) O 161 Serratia marcescens O 162 Shigella O 163 Staphylococcus, coagulase negative(not aureus) O 164 Staphylococcus aureus O 165 Staphylococcus, NOS O 166 Stomatococcus mucilaginosis O 167 Streptococcus (all species except Enterococcus) O 178 Streptococcus pneumoniae O 168 Treponema ( syphilis ) O 169 Vibrio (all species) O 197 Multiple bacteria at a single site, specify bacterial codes O 198 Other bacteria, specify O 501 Suspected atypical bacterial infection O 502 Suspected bacterial infection O 200 Candida, NOS O 201 Candida albicans O 206 Candida guillermondi O 202 Candida krusei O 207 Candida lusitaniae O 203 Candida parapsilosis O 204 Candida tropicalis O 205 Candida (Torulopsis) glabrata CIBMTR Form 2006 revision 4 (page 31 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O 209 Other Candida, specify O 210 Aspergillus, NOS O 211 Aspergillus flavus O 212 Aspergillus fumigatus O 213 Aspergillus niger O 219 Other Aspergillus, specify O 220 Cryptococcus species O 230 Fusarium species O 261 Histoplasmosis O 240 Zygomycetes, NOS O 241 Mucormycosis O 242 Rhizopus O 250 Yeast, NOS O 259 Other fungus, specify O 260 Pneumocystis (PCP / PJP) O 503 Suspected fungal infection IF (194) Specify organism code 6:= 198 Other bacteria, specify THEN GOTO (195) Specify organism: ELSE GOTO (196) Date of this product infusion: IF (194) Specify organism code 6:= 209 Other Candida, specify THEN GOTO (195) Specify organism: ELSE GOTO (196) Date of this product infusion: IF (194) Specify organism code 6:= 219 Other Aspergillus, specify THEN GOTO (195) Specify organism: ELSE GOTO (196) Date of this product infusion: IF (194) Specify organism code 6:= 259 Other fungus, specify THEN GOTO (195) Specify organism: ELSE GOTO (196) Date of this product infusion: 195 Specify organism: ________________________ ELSE GOTO (196) Date of this product infusion: Copy questions 158 - 195 if needed for Product Analysis Product Infusion Questions: 196-249 196 Date of this product infusion: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO (197) Was more than one product infused? 197 Was more than one product infused? (e.g., marrow and PBSC, PBSC and cord blood, two different cords, etc.) O yes O no IF (197) Was more than one product infused?:= yes THEN GOTO (198) Was the product infusion described on this insert intended to produce hematopoietic engraftment? ELSE GOTO (199) Date infusion started: 198 Was the product infusion described on this insert intended to produce hematopoietic engraftment? O yes O no ELSE GOTO (199) Date infusion started: 199 Date infusion started: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO (200) Time product infusion initiated (24-hour clock): 200 Time product infusion initiated (24-hour clock): ___ ___ - ___ ___ HH hour) ELSE GOTO Standard or daylight savings time MM CIBMTR Form 2006 revision 4 (page 32 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. (24 O standard time O daylight savings time ELSE GOTO (201) Date infusion stopped: CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 201 Date infusion stopped: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO (202) Time product infusion completed (24-hour clock): 202 Time product infusion completed (24-hour clock): ___ ___ - ___ ___ HH MM hour) ELSE GOTO Standard or daylight savings time (24 O standard time O daylight savings time ELSE GOTO (203) Total volume of product plus additives intended for infusion: 203 Total volume of product plus additives intended for infusion: ___ ___ ___ ___ ___ ● ___ ELSE GOTO (204) Was the entire volume of product infused? mL 204 Was the entire volume of product infused? O yes O no IF (204) Was the entire volume of product infused?:= yes THEN GOTO (207) Specify the route of product infusion ELSE GOTO (205) Specify what happened to the reserved portion 205 Specify what happened to the reserved portion O discarded O cryopreserved for future use O other fate IF (205) Specify what happened to the reserved portion:= other fate THEN GOTO (206) Specify other fate: ELSE GOTO (207) Specify the route of product infusion 206 Specify other fate: ________________________ ELSE GOTO (207) Specify the route of product infusion 207 Specify the route of product infusion O intravenous O intramedullary O intraperitoneal O other route of infusion IF (207) Specify the route of product infusion:= other route of infusion THEN GOTO (208) Specify other route of infusion: ELSE GOTO (209) Were there any adverse events or incidents associated with the stem cell infusion? 208 Specify other route of infusion: ________________________ ELSE GOTO (209) Were there any adverse events or incidents associated with the stem cell infusion? The following questions refer to all stem cell products except for autologous marrow and autologous PBSC products. If this HCT used an autologous marrow or autologous PBSC product, continue with the signature lines. 209 Were there any adverse events or incidents associated with the stem cell infusion? O yes O no IF (209) Were there any adverse events or incidents associated with the stem cell infusion?:= yes THEN GOTO (210) Brachycardia ELSE GOTO (250) Was the donor ever pregnant? Specify the following adverse event(s): 210 Brachycardia O yes O no IF (210) Brachycardia:= yes THEN GOTO (211) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (212) Chest tightness / pain 211 In the Medical Director's judgment, was the adverse event a direct result of the infusion? CIBMTR Form 2006 revision 4 (page 33 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O yes O no ELSE GOTO (212) Chest tightness / pain 212 Chest tightness / pain O yes O no IF (212) Chest tightness / pain:= yes THEN GOTO (213) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (214) Chills at time of infusion 213 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (214) Chills at time of infusion 214 Chills at time of infusion O yes O no IF (214) Chills at time of infusion:= yes THEN GOTO (215) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (216) Fever ≤ 103° F within 24 hours of infusion 215 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (216) Fever ≤ 103° F within 24 hours of infusion 216 Fever ≤ 103° F within 24 hours of infusion O yes O no IF (216) Fever ≤ 103° F within 24 hours of infusion:= yes THEN GOTO (217) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (218) Fever > 103° F within 24 hours of infusion 217 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (218) Fever > 103° F within 24 hours of infusion 218 Fever > 103° F within 24 hours of infusion O yes O no IF (218) Fever > 103° F within 24 hours of infusion:= yes THEN GOTO (219) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (220) Gross hemoglobinuria 219 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (220) Gross hemoglobinuria 220 Gross hemoglobinuria O yes O no IF (220) Gross hemoglobinuria:= yes THEN GOTO (221) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (222) Headache 221 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (222) Headache CIBMTR Form 2006 revision 4 (page 34 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 222 Headache O yes O no IF (222) Headache:= yes THEN GOTO (223) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (224) Hives 223 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (224) Hives 224 Hives O yes O no IF (224) Hives:= yes THEN GOTO (225) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (226) Hypertension 225 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (226) Hypertension 226 Hypertension O yes O no IF (226) Hypertension:= yes THEN GOTO (227) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (228) Hypotension 227 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (228) Hypotension 228 Hypotension O yes O no IF (228) Hypotension:= yes THEN GOTO (229) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (230) Hypoxia requiring oxygen (O2) support 229 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (230) Hypoxia requiring oxygen (O2) support 230 Hypoxia requiring oxygen (O2) support O yes O no IF (230) Hypoxia requiring oxygen (O2) support:= yes THEN GOTO (231) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (232) Nausea 231 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (232) Nausea 232 Nausea O yes O no IF (232) Nausea:= yes CIBMTR Form 2006 revision 4 (page 35 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ THEN GOTO (233) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (234) Rigors, mild 233 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (234) Rigors, mild 234 Rigors, mild O yes O no IF (234) Rigors, mild:= yes THEN GOTO (235) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (236) Rigors, severe 235 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (236) Rigors, severe 236 Rigors, severe O yes O no IF (236) Rigors, severe:= yes THEN GOTO (237) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (238) Shortness of breath (SOB) 237 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (238) Shortness of breath (SOB) 238 Shortness of breath (SOB) O yes O no IF (238) Shortness of breath (SOB):= yes THEN GOTO (239) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (240) Tachycardia 239 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (240) Tachycardia 240 Tachycardia O yes O no IF (240) Tachycardia:= yes THEN GOTO (241) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (242) Vomiting 241 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (242) Vomiting 242 Vomiting O yes O no IF (242) Vomiting:= yes THEN GOTO (243) In the Medical Director's judgment, was the adverse event a direct result of the infusion? ELSE GOTO (244) Other expected AE 243 In the Medical Director's judgment, was the adverse event a direct result of the infusion? CIBMTR Form 2006 revision 4 (page 36 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ O yes O no ELSE GOTO (244) Other expected AE 244 Other expected AE O yes O no IF (244) Other expected AE:= yes THEN GOTO (245) Specify other expected ae ELSE GOTO (247) Other unexpected AE 245 Specify other expected AE: ________________________ ELSE GOTO (246) In the Medical Director's judgment, was the adverse event a direct result of the infusion? 246 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (247) Other unexpected AE 247 Other unexpected AE O yes O no IF (247) Other unexpected AE:= yes THEN GOTO (248) Specify other unexpected ae ELSE GOTO (250) Was the donor ever pregnant? 248 Specify other unexpected AE: ________________________ ELSE GOTO (249) In the Medical Director's judgment, was the adverse event a direct result of the infusion? 249 In the Medical Director's judgment, was the adverse event a direct result of the infusion? O yes O no ELSE GOTO (250) Was the donor ever pregnant? Donor/Infant Demographic Information Questions: 250-285 The Donor Demographic Information section (questions 250-270) is to be completed for all non-NMDP allogeneneic donors. If the stem cell product was from an NMDP donor or an autologous donor, continue with the signature lines. 250 Was the donor ever pregnant? O Yes O No O Unknown O Not applicable (male donor or cord blood unit) IF (250) Was the donor ever pregnant?:= Yes THEN GOTO (251) Number of pregnancies ELSE GOTO (253) Specify blood type 251 Number of pregnancies O Known O Unknown IF (251) Number of pregnancies:= Known THEN GOTO (252) Specify number of pregnancies: ELSE GOTO (253) Specify blood type 252 Specify number of pregnancies: ___ ___ ELSE GOTO (253) Specify blood type 253 Specify blood type OA CIBMTR Form 2006 revision 4 (page 37 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ OB O AB OO ELSE GOTO (254) Specify Rh factor 254 Specify Rh factor O Positive O Negative ELSE GOTO (255) Did this donor have a central line placed? 255 Did this donor have a central line placed? O Yes O No O Not applicable (cord blood unit or marrow product) IF (255) Did this donor have a central line placed?:= Yes THEN GOTO (256) Specify the site of the central line placement ELSE GOTO (258) Ethnicity 256 Specify the site of the central line placement O femoral O subclavian O internal jugular O Other site IF (256) Specify the site of the central line placement:= Other site THEN GOTO (257) Specify other site: ELSE GOTO (258) Ethnicity 257 Specify other site: ________________________ ELSE GOTO (258) Ethnicity 258 Ethnicity (donor) O Hispanic or Latino O Not Hispanic or Latino O Not applicable (not a resident of the USA) O Unknown ELSE GOTO (259) Race Race 259 Race (donor) O White O Black or African American O Asian O American Indian or Alaska Native O Native Hawaiian or Other Pacific Islander O Not reported O Unknown IF (259) Race:= White THEN GOTO (260) Race detail ELSE GOTO (261) What is the biological relationship of the donor to the patient? IF (259) Race:= Black or African American THEN GOTO (260) Race detail ELSE GOTO (261) What is the biological relationship of the donor to the patient? IF (259) Race:= Asian THEN GOTO (260) Race detail ELSE GOTO (261) What is the biological relationship of the donor to the patient? IF (259) Race:= American Indian or Alaska Native THEN GOTO (260) Race detail ELSE GOTO (261) What is the biological relationship of the donor to the patient? IF (259) Race:= Native Hawaiian or Other Pacific Islander THEN GOTO (260) Race detail CIBMTR Form 2006 revision 4 (page 38 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. Questions: 259 - 260 CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO (261) What is the biological relationship of the donor to the patient? 260 Race detail (donor) O Eastern European O Mediterranean O Middle Eastern O North Coast of Africa O North American O Northern European O Western European O White Caribbean O White South or Central American O Other White O African (both parents born in Africa) O African American O Black Caribbean O Black South or Central American O Alaskan Native or Aleut O North American Indian O American Indian, South or Central America O Caribbean Indian O South Asian O Filipino (Pilipino) O Japanese O Korean O Chinese O Vietnamese O Other Southeast Asian O Guamanian O Hawaiian O Samoan O Other Pacific Islander ELSE GOTO (261) What is the biological relationship of the donor to the patient? Copy questions 259 - 260 if needed for Race 261 What is the biological relationship of the donor to the patient? O Sibling O Half-sibling O Syngeneic (identical) twin O Fraternal twin O Recipient’s child O Recipient's biological relative O Unrelated IF (261) What is the biological relationship of the donor to the patient?:= Recipient's biological relative THEN GOTO (262) Specify the biological relationship of the donor to the recipient ELSE GOTO (264) Was the donor / product tested for potentially transplantable genetic diseases? 262 Specify the biological relationship of the donor to the recipient O Mother O Father O Maternal aunt O Maternal uncle O Maternal cousin O Paternal aunt O Paternal uncle O Paternal cousin O Recipient's biological relative IF (262) Specify the biological relationship of the donor to the recipient:= Recipient's biological relative THEN GOTO (263) Specify: ELSE GOTO (264) Was the donor / product tested for potentially transplantable genetic diseases? 263 Specify: ________________________ CIBMTR Form 2006 revision 4 (page 39 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO (264) Was the donor / product tested for potentially transplantable genetic diseases? 264 Was the donor / product tested for potentially transplantable genetic diseases? O yes O no O Unknown IF (264) Was the donor / product tested for potentially transplantable genetic diseases?:= yes THEN GOTO (265) Sickle cell anemia ELSE GOTO First name IF (264) Was the donor / product tested for potentially transplantable genetic diseases?:= no AND (1) Specify donor:= REL_DNR THEN GOTO (272) Was the donor hospitalized (inpatient) during or after the collection? ELSE GOTO First name IF (264) Was the donor / product tested for potentially transplantable genetic diseases?:= Unknown AND (1) Specify donor:= REL_DNR THEN GOTO (272) Was the donor hospitalized (inpatient) during or after the collection? ELSE GOTO First name Specify disease(s) tested: 265 Sickle cell anemia O yes O no IF (265) Sickle cell anemia:= yes THEN GOTO (266) Specify results ELSE GOTO (267) Thalassemia 266 Specify results O Positive O Carrier of the trait O Negative ELSE GOTO (267) Thalassemia 267 Thalassemia O yes O no IF (267) Thalassemia:= yes THEN GOTO (268) Specify results ELSE GOTO (269) Other disease 268 Specify results O Positive O Carrier of the trait O Negative ELSE GOTO (269) Other disease 269 Other disease O yes O no IF (269) Other disease:= yes THEN GOTO (270) Specify other disease: ELSE GOTO First name IF (269) Other disease:= no AND (1) Specify donor:= REL_DNR THEN GOTO (272) Was the donor hospitalized (inpatient) during or after the collection? ELSE GOTO First name 270 Specify other disease: ________________________ ELSE GOTO (271) Specify results 271 Specify results O Positive O Carrier of the trait O Negative IF (271) Specify results:= EXISTS AND (1) Specify donor:= REL_DNR THEN GOTO (272) Was the donor hospitalized (inpatient) during or after the collection? CIBMTR Form 2006 revision 4 (page 40 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO First name The following questions (272–285) apply only to allogeneic related donors. If the stem cell product was from an autologous donor, Non-NMDP unrelated donor, NMDP donor, or was a cord blood unit, then continue with the signature lines. 272 Was the donor hospitalized (inpatient) during or after the collection? O yes O no ELSE GOTO (273) Did the donor experience any life-threatening complications during or after the collection? 273 Did the donor experience any life-threatening complications during or after the collection? O yes O no IF (273) Did the donor experience any life-threatening complications during or after the collection?:= yes THEN GOTO (274) Specify: ELSE GOTO (275) Did the donor receive blood transfusions as a result of the collection? 274 Specify: ________________________ ELSE GOTO (275) Did the donor receive blood transfusions as a result of the collection? 275 Did the donor receive blood transfusions as a result of the collection? O yes O no IF (275) Did the donor receive blood transfusions as a result of the collection?:= yes THEN GOTO (276) Was the blood transfusion product autologous? ELSE GOTO (280) Did the donor die as a result of the collection? 276 Was the blood transfusion product autologous? O yes O no IF (276) Was the blood transfusion product autologous?:= yes THEN GOTO (277) Specify number of units: ELSE GOTO (278) Was the blood transfusion product allogeneic (homologous)? 277 Specify number of units: ___ ___ ___ ELSE GOTO (278) Was the blood transfusion product allogeneic (homologous)? 278 Was the blood transfusion product allogeneic (homologous)? O yes O no IF (278) Was the blood transfusion product allogeneic (homologous)?:= yes THEN GOTO (279) Specify number of units: ELSE GOTO (280) Did the donor die as a result of the collection? 279 Specify number of units: ___ ___ ___ ELSE GOTO (280) Did the donor die as a result of the collection? 280 Did the donor die as a result of the collection? O yes O no IF (280) Did the donor die as a result of the collection?:= yes THEN GOTO (281) Specify cause of death: ELSE GOTO (282) Did the recipient submit a research sample to the NMDP/CIBMTR repository? 281 Specify cause of death: ________________________ ELSE GOTO (282) Did the recipient submit a research sample to the NMDP/CIBMTR repository? 282 Did the recipient submit a research sample to the NMDP/CIBMTR repository? (Related donors only) O yes O no IF (282) Did the recipient submit a research sample to the NMDP/CIBMTR repository?:= yes THEN GOTO (283) Research sample recipient ID: ELSE GOTO (284) Did the donor submit a research sample to the NMDP/CIBMTR repository? CIBMTR Form 2006 revision 4 (page 41 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved. CIBMTR Center Number: ___ ___ ___ ___ ___ CIBMTR Recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ 283 Research sample recipient ID: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ELSE GOTO (284) Did the donor submit a research sample to the NMDP/CIBMTR repository? 284 Did the donor submit a research sample to the NMDP/CIBMTR repository? (Related donors only) O yes O no IF (284) Did the donor submit a research sample to the NMDP/CIBMTR repository?:= yes THEN GOTO (285) Research sample donor ID: ELSE GOTO First name 285 Research sample donor ID: ELSE GOTO First name ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ First Name: ________________________ ELSE GOTO Last name Last Name: ________________________ ELSE GOTO E-mail address: E-mail address: ________________________ ELSE GOTO Date: Date: __ __ __ __ - __ __ - __ __ YYYY MM DD ELSE GOTO End of Form CIBMTR Form 2006 revision 4 (page 42 of 42) Last Updated September 4, 2013. Copyright (c) 2012 National Marrow Donor Program and The Medical College of Wisconsin, Inc. All rights reserved.

Form 2006 R4 - Center for International Blood and Marrow

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