Description:

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

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Versions (4) ▾
  1. 9/19/12
  2. 7/15/17
  3. 7/15/17
  4. 9/20/21
Uploaded on:

September 20, 2021

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License:
Creative Commons BY-NC 3.0
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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.

Registry Use Only
Identification Data
Donor Gender
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?
Hla Typing Source
Please specify the person for whom this typing is being done:
Was the recipient's mother used as the donor?
Was the recipient's father used as the donor?
Hlatyping By Dna Technology
Is a copy of the lab report attached?
Hla Typing By Dna Technology: Class I
Number of A alleles provided:
Number of B alleles provided:
Number of C alleles provided:
Hla Typing By Dna Technology: Class I
Number of DRB1 alleles provided:
Hla Typing By Dna Technology: Class Ii (optional)
Number of DRB3 alleles provided:
Number of DRB4 alleles provided:
Number of DRB5 alleles provided:
Number of DQB1 alleles provided:
Number of DPB1 alleles provided:
Number of DQA1 alleles provided?
Number of DPA1 alleles provided:
Antigens Defined By Serologic Typing
Number of A antigens provided:
1st A antigen specificity:
2nd A antigen specificity
Number of B antigens provided:
First B antigen specificity:
Second B antigen specificity:
Optional Antigen Reporting: Antigens Defined By Serologic Typing
Number of C antigens provided:
First C antigen specificity
Second C antigen specificity:
Bw4 specificity present?
Bw6 specificity present?
Number of DR antigens provided
First DR antigen specificity:
Second DR antigen specificity:
DR51 specificity present?
DR52 specificity present?
DR53 specificity present?
Number of DQ antigens provided:
First DQ antigen specificity:
Second DQ antigen specificity:
Number of DP antigens provided:
First DP antigen specificity:
Second DP antigen specificity:
Author Information

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