Description:

Infectious Disease Markers Uses The ISO Date Format Version 1 Lab - 2004 - Infectious Disease Markers ISO Date Format Version 1 - 2884169v1.0 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6A861230-7A94-FE96-E040-BB89AD434611

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6A861230-7A94-FE96-E040-BB89AD434611

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

September 20, 2021

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License:
Creative Commons BY-NC 3.0
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Infectious Disease Markers NHLBI

This form must be completed for all non-NMDP allogeneic or syngeneic donors, or non-NMDP cord blood units. If the donor or cord blood unit was secured through the NMDP, then report IDMs on forms 24 and 50 for allogeneic donors or through CORD Link for cord blood units.

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?
Source Information
Who is being tested for IDMs?
HBV
Test results of infectious disease marker for hepatitis B virus
Test results of infectious disease marker for hepatitis B virus
HCV
Test results of infectious disease marker for hepatitis C virus
Human T-lymphotropic Virus
Test results of infectious disease marker for human T-Lymphotropic virus antibody(Anti-HTLV I/II)
HIV
Test results of infectious disease marker for human immunodeficiency virus (HIV)-1 p24 antigen
Was FDA licensed nucleic acid amplification test (NAT) for human immunodeficiency virus(HIV)-1 or hepatitis C virus performed?
If FDA licensed nucleic acid amplification test (NAT)for human immunodeficiency virus(HIV)-1 performed; specify results
Was FDA licensed nucleic acid amplification test (NAT)for hepatitis C virus performed; specify results
Test results of infectious disease marker for Anti-HIV 1 and anti-HIV 2
Syphilis
Test results of infectious disease marker for syphilis using serologic testing for syphilis
CMV
Test results of infectious disease marker for cytomegalovirus(CMV) antibody (IgG or total)
WNV
Test results of infectious disease marker for west nile virus
Other Infectious Disease Marker
Other infectious disease marker?
Author Information

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