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Confirmation of HLA Typing Uses The ISO Date Format Version 1 This form must be completed for all non-NMDP allogeneic or syngeneic donors or recipients, or non-NMDP cord blood units. If the donor, recipient, or cord blood unit was secured through the NMDP, then report HLA typing on the appropriate NMDP forms. Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6AA94BD8-0ED4-61A3-E040-BB89AD434BE8

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6AA94BD8-0ED4-61A3-E040-BB89AD434BE8

Keywords:

Stem Cell Transplantation

Clinical Trial

Follow-Up Studies

Versions (4)

9/19/12 9/19/12 -
7/15/17 7/15/17 - Martin Dugas
7/15/17 7/15/17 - Martin Dugas
9/20/21 9/20/21 -

Uploaded on:

September 20, 2021

DOI:

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License :

Creative Commons BY-NC 3.0

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2005 Confirmation of HLA typing

English 1

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Details

This form must be completed for all non-NMDP allogeneic or syngeneic donors or recipients, or non-NMDP cord blood units. If the donor, recipient, or cord blood unit was secured through the NMDP, then report HLA typing on the appropriate NMDP forms.

1 forms

StudyEvent: 2005 - Confirmation of HLA typing ISO Date Format Version 1
1. This form must be completed for all non-NMDP allogeneic or syngeneic donors or recipients, or non-NMDP cord blood units. If the donor, recipient, or cord blood unit was secured through the NMDP, then report HLA typing on the appropriate NMDP forms.

Registry Use Only

Sequence number

Date received

Identification Data

CIBMTR Center Number

CIBMTR Recipient ID

Non-NMDP donor ID

Donor Gender

Male (male)

Female (female)

Donor date of birth

Non-NMDP Cord Blood Unit (CBU) ID:

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

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

Specify the other hematopoietic stem cell transplant type

Hla Typing Source

Please specify the person for whom this typing is being done:

Recipient Final Hla Typing (Recipient--final typing)

Recipient Mother Confirmed Hla Typing (Recipient's mother--confirmatory typing)

Recipient Father Confirmed Hla Typing (Recipient's father--confirmatory typing)

Donor Confirmed Hla Typing (Donor--confirmatory typing)

3 more items in the detailed view.

Was the recipient's mother used as the donor?

Yes

Was the recipient's father used as the donor?

Yes

Specify person and typing:

Hlatyping By Dna Technology

Is a copy of the lab report attached?

Yes

Hla Typing By Dna Technology: Class I

Number of A alleles provided:

Integer::1 (One)

Integer::2 (Two)

Without Analysis (Not tested)

First A* allele designations:

Second A* allele designations:

Number of B alleles provided:

Integer::1 (One)

Integer::2 (Two)

Without Analysis (Not tested)

First B* allele designations:

Second B* allele designations:

Number of C alleles provided:

Integer::1 (One)

Integer::2 (Two)

Without Analysis (Not tested)

First C* allele designations:

Second C* allele designations:

Hla Typing By Dna Technology: Class I

Number of DRB1 alleles provided:

Integer::1 (One)

Integer::2 (Two)

Without Analysis (Not tested)

First DRB1* allele designations:

Second DRB1* allele designations:

Hla Typing By Dna Technology: Class Ii (optional)

Number of DRB3 alleles provided:

Integer::1 (One)

Integer::2 (Two)

None (None)

Without Analysis (Not tested)

First DRB3* allele designations:

Second DRB3* allele designations:

Number of DRB4 alleles provided:

Integer::1 (One)

Integer::2 (Two)

None (None)

Without Analysis (Not tested)

First DRB4* allele designations:

Second DRB4* allele designations:

Number of DRB5 alleles provided:

Integer::1 (One)

Integer::2 (Two)

None (None)

Without Analysis (Not tested)

First DRB5 * allele designations:

Second DRB5 * allele designations:

Number of DQB1 alleles provided:

Integer::1 (One)

Integer::2 (Two)

First DQB1* allele designations:

Second DQB1* allele designations:

Number of DPB1 alleles provided:

Integer::1 (One)

Integer::2 (Two)

First DPB1* allele designations:

Second DPB1* allele designations:

Number of DQA1 alleles provided?

Integer::1 (One)

Integer::2 (Two)

First DQA1* allele designations:

Second DQA1* allele designations:

Number of DPA1 alleles provided:

Integer::1 (One)

Integer::2 (Two)

First DPA1* allele designations:

Second DPA1* allele designations:

Antigens Defined By Serologic Typing

Number of A antigens provided:

Integer::1 (One)

Integer::2 (Two)

1st A antigen specificity:

A1 Antigen (A1)

A2 Antigen 1st A2 Antigen (A2)

A203 Antigen (A203)

A210 Antigen (A210)

25 more items in the detailed view.

2nd A antigen specificity

A1 Antigen (A1)

A2 Antigen 1st A2 Antigen (A2)

A203 Antigen (A203)

A210 Antigen (A210)

25 more items in the detailed view.

Number of B antigens provided:

Integer::1 (One)

Integer::2 (Two)

First B antigen specificity:

B5 Antigen (B5)

B7 Antigen (B7)

B703 Antigen (B703)

B8 Antigen (B8)

57 more items in the detailed view.

Second B antigen specificity:

B5 Antigen (B5)

B7 Antigen (B7)

B703 Antigen (B703)

B8 Antigen (B8)

57 more items in the detailed view.

Optional Antigen Reporting: Antigens Defined By Serologic Typing

Number of C antigens provided:

Integer::1 (One)

Integer::2 (Two)

First C antigen specificity

Cw1 Antigen (Cw1)

Cw2 Antigen (Cw2)

Cw3 Antigen (Cw3)

Cw4 Antigen (Cw4)

7 more items in the detailed view.

Second C antigen specificity:

Cw1 Antigen (Cw1)

Cw2 Antigen (Cw2)

Cw3 Antigen (Cw3)

Cw4 Antigen (Cw4)

7 more items in the detailed view.

Bw4 specificity present?

Yes

Bw6 specificity present?

Yes

Number of DR antigens provided

Integer::1 (One)

Integer::2 (Two)

First DR antigen specificity:

Dr1 Antigen (DR1)

Dr103 Antigen (DR103)

Dr2 Antigen (DR2)

Dr3 Antigen (DR3)

18 more items in the detailed view.

Second DR antigen specificity:

Dr1 Antigen (DR1)

Dr103 Antigen (DR103)

Dr2 Antigen (DR2)

Dr3 Antigen (DR3)

18 more items in the detailed view.

DR51 specificity present?

Yes

DR52 specificity present?

Yes

DR53 specificity present?

Yes

Number of DQ antigens provided:

Integer::1 (One)

Integer::2 (Two)

First DQ antigen specificity:

Dq1 Antigen (DQ1)

Dq2 Antigen (DQ2)

Dq3 Antigen (DQ3)

Dq4 Antigen (DQ4)

6 more items in the detailed view.

Second DQ antigen specificity:

Dq1 Antigen (DQ1)

Dq2 Antigen (DQ2)

Dq3 Antigen (DQ3)

Dq4 Antigen (DQ4)

6 more items in the detailed view.

Number of DP antigens provided:

Integer::1 (One)

Integer::2 (Two)

First DP antigen specificity:

Dpw1 Antigen (DPw1)

Dpw2 Antigen (DPw2)

Dpw3 Antigen (DPw3)

Dpw4 Antigen (DPw4)

3 more items in the detailed view.

Second DP antigen specificity:

Dpw1 Antigen (DPw1)

Dpw2 Antigen (DPw2)

Dpw3 Antigen (DPw3)

Dpw4 Antigen (DPw4)

3 more items in the detailed view.

Author Information

First Name

Last Name

Telephone number:

Fax number:

EMail Address

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2005 Confirmation of HLA typing

This form must be completed for all non-NMDP allogeneic or syngeneic donors or recipients, or non-NMDP cord blood units. If the donor, recipient, or cord blood unit was secured through the NMDP, then report HLA typing on the appropriate NMDP forms.

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