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Revision 2 of Form 2005 - Confirmation of HLA Typing Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6ED9405D-0A4A-B4A1-E040-BB89AD4327FC

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https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6ED9405D-0A4A-B4A1-E040-BB89AD4327FC

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  1. 9/19/12
  2. 7/18/17
  3. 9/20/21
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September 20, 2021

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Creative Commons BY-NC 3.0
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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. A separate copy of this form should be completed for each non-NMDP donor, recipient, or cord blood unit.

Registry Use Only
Administrative Data
Specify non-NMDP donor
What is the transplant donor or infant gender?
What source was used for the hematopoietic stem cell transplantation?
What type of hematopoietic stem cell transplant was 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?
HLA Typing 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 II
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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