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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:

Laboratories

Clinical Trial

Infectious Disease Medicine

Versions (2)

12/18/14 12/18/14 - Martin Dugas
9/20/21 9/20/21 -

Uploaded on:

September 20, 2021

DOI:

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Creative Commons BY-NC 3.0 Legacy

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Lab - 2004 - Infectious Disease Markers - 2630454v6.0

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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.

1 forms

StudyEvent: 2004 - Infectious Disease Markers
1. 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

Sequence number:

Date received:

Identification Data

CIBMTR Center Number:

CIBMTR Recipient ID:

Identification Data

Non-NMDP donor ID:

Donor Gender

Male (male)

Female (female)

Donor date of birth:

Identification Data

Non-NMDP Cord Blood Unit (CBU) ID:

Identification Data

Today's date:

Date of Hematopoietic Stem Cell Transplantation (HSCT) for which this form is being completed:

Hsct Type

What source was used for the hematopoietic stem cell transplantation?

Unrelated Allogenic (Allogeneic, unrelated)

Related Allogenic (Allogeneic, related)

Syngeneic (Syngeneic (identical twin))

Was a particular hematopoietic stem cell source used?

Yes (Yes)

No (No)

Product Type

What type of hematopoietic stem cell transplant was used?

Bone Marrow (Marrow)

Peripheral Blood Stem Cell (PBSC)

Umbilical Cord Blood (Cord blood)

Other (Other)

Was a particular hematopoietic stem cell transplant type used?

Yes (Yes)

No (No)

Specify the other hematopoietic stem cell transplant type: (Answer only if the value for 2730912 is "Other". )

Source Information

Who is being tested for IDMs?

Disease Marker Donor (Donor IDM (Marrow or PBSC))

Umbilical Cord Blood Disease Marker Mother (Maternal IDM (Cord Blood))

Disease Marker Umbilical Cord Blood (Cord Blood Unit (IDM))

Infectious Disease Marker

Test results of infectious disease marker for hepatitis B virus (HBV) surface antigen(HBsAG)

Reaction (Reactive)

Not Reaction (Non-reactive)

Not Done: C49484 (Not Done)

Date that the test for hepatitis B surface antigen (HBsAG) was performed:

Test results of infectious disease marker for hepatitis B virus (HBV) core antibody (Anti HBc) (No confirmatory test available)

Reaction (Reactive)

Not Reaction (Non-reactive)

Not Done: C49484 (Not Done)

Date that the test for hepatitis B virus core antibody (Anti HBc) was performed:

Hepatitis C Virus (hcv)

Test results of infectious disease marker for hepatitis C virus (HCV) antibody (Anti-HCV)

Reaction (Reactive)

Not Reaction (Non-reactive)

Not Done: C49484 (Not Done)

Date that the test for hepatitis C virus antibody (Anti-HCV) was performed:

Human T-lymphotropic Virus

Test results of infectious disease marker for human T-Lymphotropic virus antibody(Anti-HTLV I/II):

Reaction (Reactive)

Not Reaction (Non-reactive)

Not Done: C49484 (Not Done)

Date that the test for human T-Lymphotropic virus antibody (Anti-HTLV I/II) was performed:

Human Immunodeficiency Virus (hiv)

Test results of infectious disease marker for human immunodeficiency virus(HIV)-1 p24 antigen:

Reaction (Reactive)

Not Reaction (Non-reactive)

Not Report (Not reported)

Human Immunodeficiency Virus Nucleic Acid Amplification Test Performed (Not performed; HIV NAT testing performed)

Date that the test for HIV-1 p24 antigen was performed:

Was FDA licensed nucleic acid amplification test (NAT)for human immunodeficiency virus(HIV)-1 or hepatitis C virus performed?

Yes (Yes)

No (No)

If FDA licensed nucleic acid amplification test (NAT)for human immunodeficiency virus(HIV)-1 performed; specify results

Positive Finding (Positive)

Negative Finding (Negative)

Not Report (Not reported)

Date that the FDA licensed nucleic acid amplification test (NAT) for human immunodeficiency virus (HIV-1) was performed:

Was FDA licensed nucleic acid amplification test (NAT)for hepatitis C virus performed; specify results

Positive Finding (Positive)

Negative Finding (Negative)

Date that the FDA licensed nucleic acid amplification test (NAT) for hepatitis C virus was performed:

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.)

Reaction (Reactive)

Not Reaction (Non-reactive)

Not Done: C49484 (Not Done)

Not Report (Not reported)

Date that the test for Anti-HIV 1 and anti-HIV 2 (antibodies to Human Immunodeficiency Viruses) was performed:

Syphilis

Test results of infectious disease marker for syphilis using serologic testing for syphilis(STS)

Reaction (Reactive)

Not Reaction (Non-reactive)

Not Done: C49484 (Not Done)

Date that the the serologic test for syphilis (STS) was performed:

Cytomegalovirus (cmv)

Test results of infectious disease marker for cytomegalovirus(CMV) antibody (IgG or total):

Reaction (Reactive)

Not Reaction (Non-reactive)

Previous Report Reaction (Previously reported reactive, not tested)

Not Done: C49484 (Not Done)

Date that the test for cytomegalovirus (CMV) antibody (IgG or total) was performed:

West Nile Virus (wnv)

Test results of infectious disease marker for west nile virus(WNV) using nucleic acid amplification test (NAT)

Positive Finding (Positive)

Negative Finding (Negative)

Not Done: C49484 (Not Done)

Not Applicable (Not applicable)

Date that the nucleic acid amplification test (NAT) for West Nile Viruse (WNV) was performed:

Other Infectious Disease Marker

Other infectious disease marker?

Yes (YES)

No (NO)

Date test performed on other infectious disease marker:

Specify test and method for test performed on other infectious disease marker:

Specify test results for test performed on other infectious disease marker

Author Information

First Name

Last Name

Telephone number:

Fax number:

EMail Address

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Lab - 2004 - Infectious Disease Markers - 2630454v6.0

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.

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