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ID
12452
Description
reference: http://www.ebmt.org/Contents/Data-Management/Registrystructure/MED-ABdatacollectionforms/Pages/MED-AB-data-collection-forms.aspx
Link
Keywords
Versions (2)
- 11/20/15 11/20/15 -
- 5/31/16 5/31/16 -
Uploaded on
November 20, 2015
DOI
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License
Creative Commons BY-NC 3.0
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EBMT Donor Outcome Forms
EBMT Donor Outcome Forms
- StudyEvent: ODM
Similar models
EBMT Donor Outcome Forms
- StudyEvent: ODM
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Report on donation procedure and up to 30 days after
Report on donation procedure and up to 30 days after
Item
Report on donation procedure and up to 30 days after
text
Item Group
TRANSPLANT CENTRE AND RECIPIENT IDENTIFICATION
EBMT CIC
Item
EBMT CIC
text
EBMT database number
Item
EBMT database number
integer
Center of HSCT
Item
Center of HSCT
text
Hospital/unit
Item
Hospital/unit
text
Unique Patient Number or Code
Item
Unique Patient Number or Code
integer
Initialen
Item
Initials
text
C2986440 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
Date of HSCT
Item
Date of HSCT
date
BM STEMCEDO
Item
BM STEMCEDO
boolean
PBSC
Item
PBSC
boolean
Both BM and PBSC
Item
Both BM and PBSC
boolean
Unstimulated leukapheresis
Item
Unstimulated leukapheresis
boolean
other specify product
Item
other specify product
text
Donor number/ID
Item
Donor number/ID
integer
Donor signed Informed consent for data transmission to the EBMT Registry
Item
Donor signed Informed consent for data transmission to the EBMT Registry
boolean
Initialen
Item
Initials
text
C2986440 (UMLS CUI [1])
CL Item
syngeneic (identical twin) (1)
CL Item
identical sibling/non identical twin (2)
CL Item
other family member: matched (3)
CL Item
unmatched (4)
Describe relation to the recipient
Item
Describe relation to the recipient
text
unrelated donor
Item
unrelated donor
boolean
PersonBirthDate
Item
Date of Birth
date
C0011008 (UMLS CUI [1,1])
C0027361 (UMLS CUI [1,2])
C0005615 (UMLS CUI [1,3])
C0027361 (UMLS CUI [1,2])
C0005615 (UMLS CUI [1,3])
CL Item
Male (1)
CL Item
Female (2)
First day of this collection
Item
First day of this collection
date
EBMT Code (CIC
Item
EBMT Code (CIC
integer
Collection center
Item
Collection center
text
Donor registry or CB bank
Item
Donor registry or CB bank
text
Contact person
Item
Contact person
text
Date of this report
Item
Date of this report
date
Start date of donation procedure
Item
Start date of donation procedure
date
Chronological Number of this donation procedure
Item
Chronological Number of this donation procedure
integer
Chronological Number of this donation procedure
Item
Chronological Number of this donation procedure
boolean
Centre of previous donation
Item
Centre of previous donation
text
Date of previous donation
Item
Date of previous donation
date
Was the product collection completed
Item
Was the product collection completed
boolean
Were haematopoietic growth factors used
Item
Were haematopoietic growth factors used
boolean
Were cell binding inhibitors used,
Item
Were cell binding inhibitors used,
boolean
Was erythropoietin used
Item
Was erythropoietin used
boolean
Were other drugs used for mobilization
Item
Were other drugs used for mobilization
boolean
Item Group
COMPLICATIONS in temporal association with the donation procedure
CL Item
yes (1)
CL Item
no (2)
CL Item
unknown (3)
Code 1 Serious Adverse Events (SAE/SAR) if yes
Item
Code 1 Serious Adverse Events (SAE/SAR) if yes
text
Date of the SAE/SAR
Item
Date of the SAE/SAR
date
Code 2 Serious Adverse Events (SAE/SAR) if yes
Item
Code 2 Serious Adverse Events (SAE/SAR) if yes
text
Date of the SAE/SAR
Item
Date of the SAE/SAR
date
Would the donor donate again
Item
Would the donor donate again
integer
If no: reason
Item
If no: reason
text
Item Group
Donor outcome Long term follow up report after last donation procedure
Long term follow up report after last donation procedure
Item
Long term follow up report after last donation procedure
text
Item Group
TRANSPLANT CENTRE AND RECIPIENT IDENTIFICATION
EBMT CIC
Item
EBMT CIC
text
EBMT database number
Item
EBMT database number
integer
Center of HSCT
Item
Center of HSCT
text
Hospital/unit
Item
Hospital/unit
text
Unique Patient Number or Code
Item
Unique Patient Number or Code
integer
Initials
Item
Initials
text
Date of birth
Item
Date of birth:
date
C0421451 (UMLS CUI [1])
Date of HSCT
Item
Date of HSCT
date
BM (Including collection of MSC)
Item
BM (Including collection of MSC)
boolean
PBSC
Item
PBSC
boolean
Both (BM and PBSC)
Item
Both (BM and PBSC)
boolean
Unstimulated leukapheresis
Item
Unstimulated leukapheresis
boolean
other specify produkt
Item
other specify produkt
text
Donor number/ID
Item
Donor number/ID
integer
Donor signed Informed consent for data transmission to the EBMT Registry
Item
Donor signed Informed consent for data transmission to the EBMT Registry
boolean
Initialen
Item
Initials
text
C2986440 (UMLS CUI [1])
CL Item
syngeneic (identical twin) (1)
CL Item
identical sibling/non identical twin (2)
CL Item
other family member (3)
CL Item
matched (4)
CL Item
unmatched (5)
CL Item
unrelated donor (6)
Describe relation to the recipient
Item
Describe relation to the recipient
text
TransplantDonorBirthDate
Item
Donor date of birth:
date
C0011008 (UMLS CUI [1,1])
C0040288 (UMLS CUI [1,2])
C0332835 (UMLS CUI [1,3])
C0005615 (UMLS CUI [1,4])
C0040288 (UMLS CUI [1,2])
C0332835 (UMLS CUI [1,3])
C0005615 (UMLS CUI [1,4])
CL Item
Male (1)
CL Item
Female (2)
First day of this collection
Item
First day of this collection
date
EBMT(CIC)CodeNumber
Item
EBMT Code (CIC) Number
integer
C0237753 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
C0805701 (UMLS CUI [1,3])
C0029246 (UMLS CUI [1,4])
C0805701 (UMLS CUI [1,2])
C0805701 (UMLS CUI [1,3])
C0029246 (UMLS CUI [1,4])
Collection center
Item
Collection center
text
Donor registry
Item
Donor registry
text
Contact person
Item
Contact person
text
Date of this report
Item
Date of this report
date
Start date of donation procedure
Item
Start date of donation procedure
date
Chronological Number of this donation procedure
Item
Chronological Number of this donation procedure
integer
Chronological Number of this donation procedure
Item
Chronological Number of this donation procedure
boolean
Centre of previous donation
Item
Centre of previous donation
text
Date of previous donation
Item
Date of previous donation
date
completed product collection
Item
completed product collection
boolean
haematopoietic growth factors
Item
haematopoietic growth factors
boolean
used cell binding inhibitors
Item
used cell binding inhibitors
boolean
used erythropoietin
Item
used erythropoietin
boolean
used other drugs for mobilization
Item
used other drugs for mobilization
boolean
Item Group
COMPLICATIONS in temporal association with the donation procedure
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
Code 1 Serious Adverse Events (SAE/SAR) if yes
Item
Code 1 Serious Adverse Events (SAE/SAR) if yes
text
Date of the SAE/SAR
Item
Date of the SAE/SAR
date
Code 2 Serious Adverse Events (SAE/SAR) if yes
Item
Code 2 Serious Adverse Events (SAE/SAR) if yes
text
Date of the SAE/SAR
Item
Date of the SAE/SAR
date
CL Item
no (1)
CL Item
yes (2)
CL Item
unknown (3)
reason if donor donate again
Item
reason if donor donate again
text