Description:

2300 Revision 2 - Yearly Follow-Up for Greater Than Two Years Post-HSCT Data Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=849DFDB6-D6C2-FF34-E040-BB89AD431324

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=849DFDB6-D6C2-FF34-E040-BB89AD431324

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Versions (3) ▾
  1. 9/19/12
  2. 7/18/17
  3. 9/20/21
Uploaded on:

September 20, 2021

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Creative Commons BY-NC 3.0
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Follow-Up for Greater Than Two Years Post-HSCT Data

Information should come from an actual examination by the Transplant Center physician, or the local physician who is following the recipient post-HSCT.

Registry Use Only
Identification Data
HSCT Type
HSCT type
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?
Follow Up Visit
years
Vital Status
Is the data reported on this form based on contact with the physician?
Did the recipient receive a subsequent HSCT?
Specify the recipient's survival status at the date of actual contact
Has the recipient received a donor cellular infusion?
Functional Status
Which scale was used to measure/report the functional status?
Karnofsky Performance Status Score
Lansky Performance Status Score
Specify the category which best describes the occupation of the recipient
What is the current or most recent work status?
Specify retirement level
Acute Graft versus Host Disease
Did acute GVHD develop or persist?
Was the diagnosis based on evidence from a biopsy?
What is the biopsy site used to indicate the diagnostic evidence
Specify result(s)
Is a copy of the pathology report attached?
Was the diagnosis based on clinical evidence?
Maximum overall grade of acute GVHD
Is acute GVHD still present at the date of contact for this report?
List the maximum severity of skin involvement
List the maximum severity of lower intestinal tract involvement
List the maximum severity of upper intestinal tract involvement
List the maximum severity of liver involvement
Other clinical organ involvement?
Specify the site of organ involvement
Was a particular site of organ involvement present?
Was specific therapy used to treat acute GVHD?
ALS, ALG, ATS, ATG
Specify source
Corticosteroids
Corticosteroids
Cyclosporine
ECP
FK 506
In vivo monoclonal antibody
Anti CD 25
Campath
Etanercept
Infliximab
Other in vivo monoclonal antibody
In vivo immunotoxin
Methotrexate
Mycophenolate mofetil
Sirolimus
Ursodiol
Blinded randomized trial
Other agent
Chronic Graft versus Host Disease
Did chronic GVHD develop or persist?
Onset of chronic GVHD was
Specify the functional status
What is the unit of measure for platelets?
Diagnosis was based on
Maximum grade of chronic GVHD
Overall severity of chronic GVHD
Specify the type of organ / system involvement with chronic GVHD
Indicate if there was an organ / system involvement with chronic GVHD
Indicate if the organ / system involvement was proven by biopsy
Was specific therapy used to treat chronic GVHD?
ALS, ALG, ATS, ATG
Specify source
Azathioprine
Corticosteroids
Corticosteroids
Cyclosporine
ECP
Etretinate
FK 506
Hydroxychloroquine
In vivo monoclonal antibody
Anti CD 25
Campath
Etanercept
Infliximab
Other in vivo monoclonal antibody
Lamprene
Mycophenolate mofetil
Pentostatin
PUVA
Sirolimus
Thalidomide
Ursodiol
Blinded randomized trial
Other agent
Are symptoms of chronic GVHD still present?
Is the recipient still taking immunosuppressive agents to treat or prevent GVHD?
Organ Function - New Malignancy
For all new malignancies except for "other skin malignancy (basal cell, squamous)," was testing performed to determine the cell of origin?
Specify the cell origin of the new malignancy
Is a copy of the lab report attached?
Specify which new disease(s) occurred
Did a new malignancy occur?
Is the tumor EBV positive?
Is a pathology / autopsy report or other documentation attached?
Organ Function - Other Organ Impairment / Disorder
Has the recipient developed any other clinically significant organ impairment or disorder?
Specify impairment / disorder
Did a particular type of organ impairment / disorder occur?
Did the recipient receive plasmapheresis?
Did the recipient receive dialysis?
Subsequent HSCT
Was the subsequent HSCT performed at a different institution?
What was the indication for the subsequent HSCT?
Source of HSCs
Was the same donor used?
Specify
Donor Cellular Infusion (DCI) Information
Was the DCI infusion performed at a different institution?
Indication for DCI
Molecular
Cytogenetic
Clinical evidence / hematologic
Was chemotherapy used to attempt to induce disease response?
Specify the viral organism
What was the recipient´s disease status?
Specify the functional status
Collected at the time of PBSC mobilization and collection
Negative fraction of CD34 selected PBSC
Negative fraction of CD34 selected bone marrow
Apheresis at a different time than collection of PBSC used for allogeneic HSCT
Isolated from a unit
Were the donor cells collected by leukapheresis?
Did the donor receive treatment to enhance cell collection prior to donation?
Growth factor
G-CSF
GM-CSF
Other agent
Other treatment
Were dendritic cells infused?
Were fibroblasts infused?
Were any other cell types infused?
Were the cells cryopreserved prior to infusion?
Specify portion of cells cryopreserved prior to infusion
Was the product manipulated prior to infusion?
Specify portion manipulated
ABO incompatibility
Buffy coat preparation
Cell separator
Density gradient separation
Plasma removal
Sedimentation
Other
Dextran-albumin wash
Ex-vivo expansion
Genetic manipulation
Volume reduction
CD34+ selection
Specify manufacturer
T-cell depletion
Antibody affinity column
Antibody coated plates
Antibody coated plates and soybean lectin
Antibody and complement
Antibody and toxin
Immunomagnetic beads
Elutriation
CD34 affinity column plus sheep red blood cell rosetting
Other
Other manipulation
Were antibodies used during graft manipulation?
Anti CD2
Anti CD4
Anti CD5
Anti CD6
Anti CD7
Anti CD8
Anti CD34
Anti TCR alpha / beta
OKT-3
Other CD3
Anti CD52
Campath-NOS
Campath-1G
Campath-1H
Other antibody
Author Information

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