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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

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 9/19/12 -
7/18/17 7/18/17 - Martin Dugas
9/20/21 9/20/21 -

Uploaded on:

September 20, 2021

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Creative Commons BY-NC 3.0

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HLA Typing

English 1

English

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.

1 forms

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

Administrative Data

CIBMTR Center Number

CIBMTR Recipient ID

Specify non-NMDP donor

Donor Relationship (Related donor)

Negation National Marrow Donor Program Donor Unrelated (Non-NMDP unrelated donor)

Negation National Marrow Donor Program Umbilical Cord Blood Unit (Non-NMDP cord blood unit)

Donor date of birth

What is the transplant donor or infant gender?

Female (female)

Male (male)

Non-NMDP unrelated donor / cord blood unit ID

Today's date

Date of hematopoietic stem cell transplantation (HSCT) for which this form is being completed

What source was used for the hematopoietic stem cell transplantation?

Unrelated Allogenic (Allogeneic, unrelated)

Related Allogenic (Allogeneic, related)

Syngeneic (Syngeneic (identical twin))

What type of hematopoietic stem cell transplant was used?

Bone Marrow (Marrow)

Peripheral Blood Stem Cell (PBSC)

Umbilical Cord Blood (Cord blood)

Other (Other)

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

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

HLA Typing by DNA Technology: Class II (Optional)

Number of DRB3 alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

First DRB3* allele designations

Second DRB3* allele designations

Number of DRB4 alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

First DRB4* allele designations

Second DRB4* allele designations

Number of DRB5 alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

First DRB5* allele designations

Second DRB5* allele designations

Number of DQB1 alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

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?

1 (One)

2 (Two)

Without Analysis (Not tested)

First DQA1* allele designations

Second DQA1* allele designations

Number of DPA1 alleles provided

1 (One)

2 (Two)

Without Analysis (Not tested)

First DPA1* allele designations

Second DPA1* allele designations

Antigens Defined By Serologic Typing

Number of A antigens provided

1 (One)

2 (Two)

Without Analysis (Not tested)

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

1 (One)

2 (Two)

Without Analysis (Not tested)

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

1 (One)

2 (Two)

Without Analysis (Not tested)

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

1 (One)

2 (Two)

Without Analysis (Not tested)

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

1 (One)

2 (Two)

Without Analysis (Not tested)

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

1 (One)

2 (Two)

Without Analysis (Not tested)

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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