Description:

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

Link:

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

Keywords:

Clinical Trial

Histocompatibility Testing

Major Histocompatibility Complex

HLA Antigens

Follow-Up Studies

Versions (3) ▾

9/19/12
7/18/17
9/20/21

Uploaded on:

September 20, 2021

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Creative Commons BY-NC 3.0

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HLA Typing

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

StudyEvent: 2005 Revision 2 - Confirmation of HLA Typing
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. A separate copy of this form should be completed for each non-NMDP donor, recipient, or cord blood unit.

Registry Use Only

Sequence number

Date received

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

HLA Typing by DNA Technology

Is a copy of the lab report attached?

Yes

HLA Typing by DNA Technology: Class I

Number of A alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

First A* allele designations

Second A* allele designations

Number of B alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

First B* allele designations

Second B* allele designations

Number of C alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

First C* allele designations

Second C* allele designations

HLA Typing by DNA Technology: Class II

Number of DRB1 alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

First DRB1* allele designations

Second DRB1* allele designations

Author Information

First Name

Last Name

Telephone number

Fax number

EMail Address

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