Description:

Infectious Disease Markers Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=62093463-23EF-B53C-E040-BB89AD434539

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=62093463-23EF-B53C-E040-BB89AD434539

Keywords:
Versions (2) ▾
  1. 12/18/14
  2. 9/20/21
Uploaded on:

September 20, 2021

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License:
Creative Commons BY-NC 3.0 Legacy
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Lab - 2004 - Infectious Disease Markers - 2630454v6.0

Details

This form must be completed for all non-NMDP allogeneic or syngeneic donors, or non-NMDP cord blood units. If the donor or cord blood unit was secured through the NMDP, then report IDMs on forms 24 and 50 for allogeneic donors or through CORD Link for cord blood units.

Registry Use Only
Identification Data
Identification Data
Donor Gender
Identification Data
Identification Data
Hsct Type
What source was used for the hematopoietic stem cell transplantation?
Was a particular hematopoietic stem cell source used?
Product Type
What type of hematopoietic stem cell transplant was used?
Was a particular hematopoietic stem cell transplant type used?
Source Information
Who is being tested for IDMs?
Infectious Disease Marker
Test results of infectious disease marker for hepatitis B virus (HBV) surface antigen(HBsAG)
Test results of infectious disease marker for hepatitis B virus (HBV) core antibody (Anti HBc) (No confirmatory test available)
Hepatitis C Virus (hcv)
Test results of infectious disease marker for hepatitis C virus (HCV) antibody (Anti-HCV)
Human T-lymphotropic Virus
Test results of infectious disease marker for human T-Lymphotropic virus antibody(Anti-HTLV I/II):
Human Immunodeficiency Virus (hiv)
Test results of infectious disease marker for human immunodeficiency virus(HIV)-1 p24 antigen:
Was FDA licensed nucleic acid amplification test (NAT)for human immunodeficiency virus(HIV)-1 or hepatitis C virus performed?
If FDA licensed nucleic acid amplification test (NAT)for human immunodeficiency virus(HIV)-1 performed; specify results
Was FDA licensed nucleic acid amplification test (NAT)for hepatitis C virus performed; specify results
Test results of infectious disease marker for Anti-HIV 1 and anti-HIV 2 (antibodies to Human Immunodeficiency Viruses): (Testing for both HIV antibodies is required. This testing may be performed as separate tests or done using a combined assay.)
Syphilis
Test results of infectious disease marker for syphilis using serologic testing for syphilis(STS)
Cytomegalovirus (cmv)
Test results of infectious disease marker for cytomegalovirus(CMV) antibody (IgG or total):
West Nile Virus (wnv)
Test results of infectious disease marker for west nile virus(WNV) using nucleic acid amplification test (NAT)
Other Infectious Disease Marker
Other infectious disease marker?
Author Information
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