Información:
Error:
ID
6372
Descripción
Hematopoietic Stem Cell Transplant (HSCT) Infusion ISO Date Format Version 1 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=
Link
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=
Palabras clave
Versiones (1)
- 18/12/14 18/12/14 - Martin Dugas
Subido en
18 de diciembre de 2014
DOI
Para solicitar uno, por favor iniciar sesión.
Licencia
Creative Commons BY-NC 3.0 Legacy
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Treatment - Hematopoietic Stem Cell Transplant (HSCT) Infusion ISO Date Format Version 1 - 2894050v2.0
This form must be completed for all recipients who receive a HSCT product. If multiple HSCT products are infused it must be reported separately. A series of collections should be considered a single product when they are all from the same donor and use the same collection method and technique (and mobilization, if applicable), even if the collections are performed on different days.
Similar models
This form must be completed for all recipients who receive a HSCT product. If multiple HSCT products are infused it must be reported separately. A series of collections should be considered a single product when they are all from the same donor and use the same collection method and technique (and mobilization, if applicable), even if the collections are performed on different days.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
ClinicalDataFormSequenceNumber
Item
Sequence number:
double
ClinicalDataFormReceivedDate
Item
Date received:
date
HematopoieticStemCellTransplantationRecipientInstitution::CenterforInternationalBloodandMarrowTransplantResearchFacilityNumber
Item
CIBMTR Center Number:
double
HematopoieticStemCellTransplantationRecipientIdentificationNumber
Item
CIBMTR Recipient ID:
double
HematopoieticStemCellTransplantationTissueDonorIdentificationNumber
Item
Donor ID:
double
HematopoieticStemCellTransplantationUmbilicalCordBloodTypeInstitution::NationalMarrowDonorProgramIdentifier
Item
NMDP Cord Blood Unit ID:
double
Item
Non-NMDP Cord Blood Unit :
text
CL Item
Yes (Yes)
ClinicalDataFormTodayDate
Item
Today's date:
date
HematopoieticStemCellTransplantationOccurrenceDate
Item
Date of hematopoietic stem cell transplantation (HSCT) for which this form is being completed:
date
Item
What source was used for the hematopoietic stem cell transplantation?
text
CL Item
Autologous (Autologous)
CL Item
Unrelated Allogenic (Allogeneic, unrelated)
CL Item
Related Allogenic (Allogeneic, related)
CL Item
Syngeneic (Syngeneic (identical twin))
Item
Was a particular hematopoietic stem cell source used?
text
CL Item
Yes (Yes)
Item
What type of hematopoietic stem cell transplant was used?
text
CL Item
Bone Marrow (Marrow)
CL Item
Peripheral Blood Stem Cell (PBSC)
CL Item
Umbilical Cord Blood (Cord blood)
CL Item
Multiple Umbilical Cord Blood (Multiple cord blood units infused)
CL Item
Other (Other)
Item
Was a particular hematopoietic stem cell transplant type used?
text
CL Item
Yes (Yes)
HematopoieticStemCellGraftOtherTypeSpecify
Item
Specify the other hematopoietic stem cell transplant type: (Answer only if the value for 2730912 is "Other". )
text
Item
Did the donor receive treatment, prior to any stem cell harvest, to enhance the product collection for this HSCT?
text
Code List
Did the donor receive treatment, prior to any stem cell harvest, to enhance the product collection for this HSCT?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
National Marrow Donor Program Donor (NMDP donor)
CL Item
Umbilical Cord Blood Unit (Cord blood unit)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Anti-CD20(rituximab,Rituxan) (autologous only)
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Other growth factor(s)
text
CL Item
Yes (Yes)
CL Item
No (No)
PriorHarvestProcedureTissueDonorTreatOtherHematopoieticGrowthFactorTherapiesSpecify
Item
Specify (Answer only if the value for 2772114 is "Yes")
text
CL Item
Yes (Yes)
CL Item
No (No)
PriorHarvestProcedureTissueDonorOtherTreatSpecify
Item
Specify treatment: (Answer only if the value for 2773751 is "Yes")
text
HematopoieticStemCellGraftCollectionDate
Item
Date of product collection:
date
Item
Was more than one collection required for this HSCT?
text
CL Item
Yes (Yes)
CL Item
No (No)
MultipleHematopoieticStemCellCollectionNextDayCount
Item
Specify the number of subsequent days of collection in this episode: (Complete a separate product form for each subsequent collection that was not part of this mobilization.)
double
Item
Were anticoagulants added to the product during collection?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
What anticoagulants were added to the product during collection?
text
CL Item
Acid-citrate-dextrose (Acid-Citrate-Dextrose (ACD))
CL Item
Citrate Phosphate Dextrose (Citrate Phosphate Dextrose (CPD))
CL Item
Heparin (Heparin)
CL Item
Other (Other)
Item
Were particular anticoagulants added to the product during collection?
text
CL Item
Yes (Yes)
CL Item
No (No)
DuringCollectionHematopoieticStemCellGraftCombinedOtherAnticoagulantAgentAdministrationTherapiesSpecify
Item
Specify the other anticoagulants (Answer only if the value for 2741578 is "Other")
text
Item
Was this product collected off-site and shipped to your facility?
text
CL Item
Yes (Yes)
CL Item
No (No)
HematopoieticStemCellGraftAtFacilityReceivedDate
Item
Date of receipt of product at your facility:
date
HematopoieticStemCellGraftReceivedHourMinuteTime
Item
Time of receipt of product: (24-hour clock)
time
Item
Is time of receipt of product standard time or daylight savings time?
text
CL Item
Standard Time (Standard time)
CL Item
Daylight Savings Time (Daylight Savings Time)
Item
Specify the shipping environment of the product(s):
text
CL Item
Freezing Gel Pack (Frozen Gel Pack)
CL Item
Freezing Umbilical Cord Blood Storage Unit (Frozen Cord Blood Unit (s))
CL Item
Ambient Temperature (Room Temperature per Transplant Center Request)
CL Item
Other Temperature (Other Temperature)
HematopoieticStemCellGraftArrivalFacilityShippingEnvironmentSpecifyText
Item
Specify shipping environment:
text
Item
Were the secondary containers (e.g., insulated shipping containers and unit cassette) intact when they arrived at your center? (Cord blood product only)
text
Code List
Were the secondary containers (e.g., insulated shipping containers and unit cassette) intact when they arrived at your center? (Cord blood product only)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Was the cord blood unit completely frozen when it arrived at your center? (Cord blood product only)
text
Code List
Was the cord blood unit completely frozen when it arrived at your center? (Cord blood product only)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Was the cord blood unit stored at your center prior to thawing? (Cord blood product only)
text
Code List
Was the cord blood unit stored at your center prior to thawing? (Cord blood product only)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Specify the storage method used for the cord blood unit:
text
CL Item
Liquid Nitrogen (Liquid Nitrogen)
CL Item
Vapor Phase Cooling (Vapor Phase)
CL Item
Electricity Freezing (Electric Freezer)
UmbilicalCordBloodPriorThawAtFacilityStorageCelsiusScaleValue
Item
Temperature during storage:
double
UmbilicalCordBloodPriorThawAtFacilityStorageBeginDate
Item
Date storage started:
date
Item
Was a fresh product received, then cryopreserved at your facility prior to infusion?
text
Code List
Was a fresh product received, then cryopreserved at your facility prior to infusion?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not Applicable (Not Applicable)
Item
Was the product thawed from a cryopreserved state prior to infusion?
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Was a compartment of the bag thawed?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Were there multiple product bags?
text
CL Item
Yes (Yes)
CL Item
No (No)
PriorInfusionHematopoieticStemCellGraftMultipleBagDosingUnitThawCount
Item
Specify number of bags thawed:
double
HematopoieticStemCellGraftThawPriorInfusionBeginDate
Item
Date thawing process initiated:
date
HematopoieticStemCellGraftThawPriorInfusionBeginTime
Item
Time at initiation of thaw: (24-hour clock)
time
Item
Is the thawing begin time standard time or daylight savings time?
text
CL Item
Standard Time (Standard time)
CL Item
Daylight Savings Time (Daylight Savings Time)
HematopoieticStemCellGraftThawPriorInfusionEndTime
Item
Time at completion of thaw : (24-hour clock)
time
Item
Is the thawing end time standard time or daylight savings time?
text
CL Item
Standard Time (Standard time)
CL Item
Daylight Savings Time (Daylight Savings Time)
Item
Was the primary container (e.g.,cord blood unit bag) intact upon thawing?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
What method was used to thaw the product?
text
CL Item
No Cell Wash (no wash - thawed at bedside,then infused)
CL Item
Dimethyl Sulfoxide Dilute (DMSO dilution - thawed in lab (added dextran and albumin), then infused)
CL Item
Cell Wash (washed - thawed in lab (added dextran and albumin),spun and reconstituted in dextran albumin,then infused)
CL Item
Other Method (other method)
HematopoieticStemCellGraftOtherThawMethodTypeSpecify
Item
Specify other thaw method: (Answer only if the value for 2789998 is "Other method")
text
Item
Did any adverse events or incidents occur while thawing the product?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item Group
Product Processing / Manipulation - Part 2
Item
Was the product manipulated prior to infusion?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Specify portion manipulated:
text
CL Item
Entire Hematopoietic Stem Cell Collection (Entire product)
CL Item
Part Hematopoietic Stem Cell Collection (Portion of product)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Buffy coat preparation
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Cell separator (i.e., COBE Spectra)
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Density gradient separation (i.e., Ficoll)
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Sedimentation (i.e., hetastarch)
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
ErythrocyteCountReducedMethodOtherPerformedSpecify
Item
Specify: (Answer only if the value for 2774524 is "Yes" )
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Genetic manipulation (gene transfer / transduction)
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
CD34+ selection
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Specify cell selection system used:
text
CL Item
Clinimax Cell Selection System (CliniMACS / CliniMax)
CL Item
Isolex Cell Selection System (Isolex)
CL Item
Other (Other)
HematopoieticProgenitorCellAntigenCD34PositiveSelectionHematopoieticStemCellGraftManipulationOtherDiagnostic,Therapeutic,andResearchEquipmentTherapiesSpecify
Item
Specify system: (Answer only if the value for 2786700 is "Other" )
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
antibody coated plates and soybean lectin
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
immunomagnetic beads
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
CD34 affinity column plus sheep red blood cell rosetting
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
T-CellDepletionMethodOtherPerformedTherapiesSpecify
Item
Specify: (Answer only if the value for 2774740 is "Yes" )
text
CL Item
Yes (Yes)
CL Item
No (No)
HematopoieticStemCellGraftManipulationOtherTechniqueTherapiesSpecify
Item
Specify: (Answer only if the value for 2744934 is "Yes" )
text
Item
Were antibodies used during product manipulation?
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
anti CD5
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
anti CD6
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
anti CD7
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
anti CD8
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
anti CD34
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
anti TCR alpha / beta (T10-B9)
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
other CD3
text
CL Item
Yes (Yes)
CL Item
No (No)
DuringHematopoieticStemCellGraftManipulationOtherCD3ComplexAdministeredSpecify
Item
Specify (Answer only if the value for 2746342 is "Yes" )
text
Item
anti CD52
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
campath-NOS
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
Item
other antibody
text
CL Item
Yes (Yes)
CL Item
No (No)
DuringHematopoieticStemCellGraftManipulationOtherAntibodyAdministeredTherapiesSpecify
Item
Specify: (Answer only if the value for 2746486 is "Yes" )
text
Item
Were tumor cells detected in the recipient or autologous product prior to HSCT?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
What tumor cell detection method was used ?
text
CL Item
Histopathology (Routine histopathology)
CL Item
Pcr, Polymerase Chain Reaction (Polymerase chain reaction(PCR))
CL Item
Other Molecular Techniques (Other molecular technique)
CL Item
Ihc, Immunohistochemistry (Immunohistochemistry)
CL Item
Cell Culture Techniques (Cell culture technique)
CL Item
Other (Other)
Item
Were particular tumor cell detection method used prior to HSCT?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Were tumor cells detected in circulating blood cells prior to HSCT?
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not Done: C49484 (Not Done)
Item
Were tumor cells detected in bone marrow, in the interval between last systemic therapy and collection prior to HSCT?
text
Code List
Were tumor cells detected in bone marrow, in the interval between last systemic therapy and collection prior to HSCT?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not Done: C49484 (Not Done)
Item
Were tumor cells detected in collected cells, before purging prior to HSCT?
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not Done: C49484 (Not Done)
PriorHematopoieticStemCellTransplantationNeoplasticCellDetectionOtherMethodOccurrenceTherapiesSpecify
Item
Specify method (Answer only if the value for 2775544 is "Other molecular technique" OR "Other technique" )
text
Item
Was the product treated to remove malignant cells (purged) ? (autologous product only)
text
Code List
Was the product treated to remove malignant cells (purged) ? (autologous product only)
CL Item
Yes (Yes)
CL Item
No (No)
Item
What malignant cell removal method was used to treat the product?
text
CL Item
Monoclonal Antibody (Monoclonal antibody)
CL Item
Perfosfamide (4-hydroperoxycyclophosphamide(4HC))
CL Item
Mafosfamide (Mafosfamide)
CL Item
Other Medication (Other drug)
CL Item
Elutriative Centrifugation (Elutriation)
CL Item
Immunomagnetic Column (Immunomagnetic column)
CL Item
Toxin (Toxin)
CL Item
Hematopoietic Stem Cell Positive Selection (Positive stem cell selection(other than preparation of mononuclear fraction))
CL Item
Other Method (Other method)
Item
Was a particular malignant cell removal method used for product treatment?
text
CL Item
Yes (Yes)
CL Item
No (No)
MalignantCellRemovedOtherMethodOccurrenceTherapiesSpecify
Item
Specify the other malignant cell removal method: (Answer only if the value for 2748795 is "Monoclonal antibody","Other drug", "Toxin","Positive stem cell selection" or "Other method".)
text
Item
What kind of method was used to detect tumor cells after purging?
text
CL Item
Histopathology (Routine histopathology)
CL Item
Pcr, Polymerase Chain Reaction (Polymerase chain reaction(PCR))
CL Item
Other Molecular Techniques (Other molecular technique)
CL Item
Ihc, Immunohistochemistry (Immunohistochemistry)
CL Item
Cell Culture Techniques (Cell culture technique)
CL Item
Other (Other)
Item
Was a particular tumor cell detection method used after purging?
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not Done: C49484 (Not Done)
PostMalignantCellRemovedNeoplasticCellDetectionOtherMethodOccurrenceTherapiesSpecify
Item
Specify the other tumor cells detection method (Answer only if the value for 2778929 is "Other")
text
Item
Specify the time point in the product preparation that the product was analyzed:
text
CL Item
Arrival (Product arrival)
CL Item
Post Processing Prior Cryopreservation Prior Manipulation (Post-processing, pre-cryopreservation / manipulation)
CL Item
Post Thaw (Post-thaw)
CL Item
Post Manipulation (Post-manipulation)
CL Item
Infusion Timepoint (At infusion (final quantity infused))
HematopoieticStemCellGraftLaboratoryProcedureDate
Item
Date of product analysis:
date
HematopoieticStemCellGraftLaboratoryProcedureTotalVolumeValue
Item
Total volume of product: (one decimal place)
double
Item
What was the unit of measure for the total volume of the product being analyzed?
text
CL Item
Milliliter (mL)
CL Item
Gram (g)
NucleatedBloodCellLaboratoryProcedureCellTotalInteger::2DecimalPlaceCount
Item
Nucleated cells: (Report the total number of cells not cells per kilogram)
double
NucleatedBloodCellLaboratoryProcedureExponentValue
Item
Nucleated cells exponent value:
double
Item
Not tested (Not tested for nucleated cells)
text
CL Item
Negation Test (Not tested)
MononucleatedBloodCellLaboratoryProcedureCellTotalInteger::2DecimalPlaceCount
Item
Mononucleated cells: (Report the total number of cells not cells per kilogram)
double
MononucleatedBloodCellLaboratoryProcedureExponentValue
Item
Mononucleated cells exponent value:
double
Item
Not tested (Not tested for mononucleated cells)
text
CL Item
Negation Test (Not tested)
NucleatedRedBloodCellLaboratoryProcedureCellTotalInteger::2DecimalPlaceCount
Item
Nucleated red blood cells: (Report the total number of cells not cells per kilogram)
double
NucleatedRedBloodCellLaboratoryProcedureExponentValue
Item
Nucleated red blood cells exponent value:
double
Item
Not tested (Not tested for nucleated red blood cells)
text
CL Item
Negation Test (Not tested)
HematopoieticProgenitorCellAntigenCD34PresentCellLaboratoryProcedureCellTotalInteger::2DecimalPlaceCount
Item
CD34+ cells: (Report the total number of cells not cells per kilogram)
double
HematopoieticProgenitorCellAntigenCD34PresentCellLaboratoryProcedureExponentValue
Item
CD34+ cells exponent value:
double
Item
Not tested (Not tested for CD34+ cells)
text
CL Item
Negation Test (Not tested)
CD3ComplexPresentCellLaboratoryProcedureCellTotalInteger::2DecimalPlaceCount
Item
CD3+ cells: (Report the total number of cells not cells per kilogram)
double
CD3ComplexPresentCellLaboratoryProcedureExponentValue
Item
CD3+ cells exponent value:
double
Item
Not tested (Not tested for CD3+ cells)
text
CL Item
Negation Test (Not tested)
CD4AntigenPresentCellLaboratoryProcedureCellTotalInteger::2DecimalPlaceCount
Item
CD4+ cells: (Report the total number of cells not cells per kilogram)
double
CD4AntigenPresentCellLaboratoryProcedureExponentValue
Item
CD4+ cells exponent value:
double
Item
Not tested (Not tested for CD4+ cells)
text
CL Item
Negation Test (Not tested)
CD8-PositiveT-LymphocytePresentCellLaboratoryProcedureCellTotalInteger::2DecimalPlaceCount
Item
CD8+ cells: (Report the total number of cells not cells per kilogram)
double
CD8-PositiveT-LymphocytePresentCellLaboratoryProcedureExponentValue
Item
CD8+ cells exponent value:
double
Item
Not tested (Not tested for CD8+ cells)
text
CL Item
Negation Test (Not tested)
LaboratoryProcedureViableCellSpecimenOutcomePercentageValue
Item
Viability of cells
double
Item
Not tested (The cell viability not tested)
text
CL Item
Negation Test (Not tested)
CL Item
7-aminoactinomycin D (7-AAD)
CL Item
Propidium Iodide (Propidium iodide)
CL Item
Trypan Blue (Trypan blue)
CL Item
Other Method (Other method)
LaboratoryProcedureViableCellSpecimenOutcomeSpecify
Item
Specify other method: (Answer only if the value for 2760530 is "Other method")
text
Item
Were the colony-forming units (CFU) assessed after thawing? (cord blood product only)
text
Code List
Were the colony-forming units (CFU) assessed after thawing? (cord blood product only)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
LaboratoryProcedurePostThawColonyFormingUnitOutcomeTotalColonyCount
Item
Total colonies per product: (One decimal place with exponent "x10E5")
double
Item
Unknown (Total colonies per productunknown )
text
CL Item
Unknown Not Applicable (Unknown/not applicable)
ColonyFormingUnitLaboratoryProcedurePostThawPerformedTotalColony-FormingUnit-GranulocyteMacrophageAssayCount
Item
Total CFU-GM: (One decimal place with exponent "x10E5")
double
Item
Unknown (Total CFU-GMUnknown )
text
CL Item
Unknown Not Applicable (Unknown/not applicable)
Item
Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? (complete for all cell products)
text
Code List
Were cultures performed before infusion to test the product(s) for bacterial or fungal infection? (complete for all cell products)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Specify results:
text
CL Item
Positive Finding (Positive)
CL Item
Negative Finding (Negative)
CL Item
Unknown (Unknown)
Item
Specify organism names: (1st Organism Name)
text
CL Item
Acinetobacter (Acinetobacter)
CL Item
Actinomyces (Actinomyces)
CL Item
Bacillus (Bacillus)
CL Item
Bacteroides (Bacteroides (gracillis, uniformis, vulgaris, other species))
CL Item
Bordetella Pertussis (Bordetella pertussis (whooping cough))
CL Item
Borrelia Burgdorferi (Borrelia (lyme disease))
CL Item
Moraxella Catarrhalis (Branhamella or Moraxella catarrhalis (other species))
CL Item
Campylobacter (Campylobacter (all species))
CL Item
Capnocytophaga (Capnocytophaga)
CL Item
Chlamydophila Pneumoniae (Chlamydia (pneumoniae))
CL Item
Other Chlamydia (Other chlamydia)
CL Item
Chlamydia Not Otherwise Specified (Chlamydia, NOS)
CL Item
Citrobacter (Citrobacter (freundii, other species))
CL Item
Clostridium (Clostridium (all species except difficile))
CL Item
Clostridium Difficile (Clostridium difficile)
CL Item
Corynebacterium Jeikeium (Corynebacterium (jeikeium))
CL Item
Corynebacterium (Corynebacterium (all non-diptheria species))
CL Item
Coxiella (Coxiella)
CL Item
Enterobacter (Enterobacter)
CL Item
Vancomycin Resistant Enterococcus (Enterococcus, vancomycin resistant (VRE))
CL Item
Enterococcus (Enterococcus (all species))
CL Item
Escherichia Coli (Escherichia (also E. coli))
CL Item
Pseudomonas Oryzihabitans (Flavimonas oryzihabitans)
CL Item
Flavobacterium (Flavobacterium)
CL Item
Fusobacterium (Fusobacterium)
CL Item
Haemophilus (Haemophilus (all species, including influenzae))
CL Item
Helicobacter Pylori (Helicobacter pylori)
CL Item
Klebsiella (Klebsiella)
CL Item
Lactobacillus (Lactobacillus (bulgaricus, acidophilus, other species))
CL Item
Legionella (Legionella)
CL Item
Leptospira (Leptospira)
CL Item
C76356 (Leptotrichia buccalis)
CL Item
Leuconostoc (Leuconostoc (all species))
CL Item
Listeria (Listeria)
CL Item
Methylobacterium (Methylobacterium)
CL Item
Micrococcus Not Otherwise Specified (Micrococcus, NOS)
CL Item
Mycobacterium Avium Complex (Mycobacterium avium - intracellulare (MAC, MAI))
CL Item
Mycobacterium Species (Mycobacterium species (cheloneae, fortuitum, haemophilum, kansasii, mucogenicum))
CL Item
Mycobacterium Tuberculosis (Mycobacterium tuberculosis (tuberculosis, Koch bacillus))
CL Item
Other Mycobacterium (Other mycobacterium)
CL Item
Mycobacterium Not Otherwise Specified (Mycobacterium, NOS)
CL Item
Mycoplasma (Mycoplasma)
CL Item
Neisseria (Neisseria (gonorrhoeae, meningitidis, other species))
CL Item
Nocardia (Nocardia)
CL Item
Pasteurella Multocida (Pasteurella multocida)
CL Item
Propionibacterium Acnes (Propionibacterium (acnes, avidum, granulosum, other species))
CL Item
Proteus (Proteus)
CL Item
Pseudomonas (Pseudomonas (all species except cepacia & maltophilia))
CL Item
Burkholderia Cepacia (Pseudomonas or Burkholder cepacia)
CL Item
Stenotrophomonas Maltophilia (Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia)
CL Item
Rhodococcus (Rhodococcus)
CL Item
Rickettsia (Rickettsia)
CL Item
Salmonella (Salmonella (all species))
CL Item
Serratia Marcescens (Serratia marcescens)
CL Item
Shigella (Shigella)
CL Item
Staphylococcus Coag Negative (Staphylococcus, coagulase negative)
CL Item
Staphylococcus Aureus (Staphylococcus aureus)
CL Item
Streptococcus Not Otherwise Specified (Staphylococcus, NOS)
CL Item
Rothia Mucilaginosa (Stomatococcus mucilaginosis)
CL Item
Streptococcus (Streptococcus (all species except Enterococcus))
CL Item
Streptococcus Pneumoniae (Streptococcus pneumoniae)
CL Item
Treponema (Treponema (syphilis))
CL Item
Vibrio (Vibrio (all species))
CL Item
Multiple Bacteria (Multiple bacteria at a single site)
CL Item
Other Bacteria (Other bacteria)
CL Item
Suspected Atypical Bacteria Infection (Suspected atypical bacterial infection)
CL Item
Suspected Bacteria Infection (Suspected bacterial infection)
CL Item
Candida Not Otherwise Specified (Candida, NOS)
CL Item
Candida Albicans (Candida albicans)
CL Item
Pichia Guilliermondii (Candida guillermondi)
CL Item
Issatchenkia Orientalis (Candida krusei)
CL Item
Clavispora Lusitaniae (Candida lusitaniae)
CL Item
Candida Parapsilosis (Candida parapsilosis)
CL Item
Candida Tropicalis (Candida tropicalis)
CL Item
Candida Glabrata (Candida (Torulopsis) glabrata)
CL Item
Other Candida (Other Candida)
CL Item
Aspergillus Not Otherwise Specified (Aspergillus, NOS)
CL Item
Aspergillus Flavus (Aspergillus flavus)
CL Item
Aspergillus Fumigatus (Aspergillus fumigatus)
CL Item
Aspergillus Niger (Aspergillus niger)
CL Item
Other Aspergillus (Other Aspergillus)
CL Item
Cryptococcosis (Cryptococcosus species)
CL Item
Fusarium (Fusarium species)
CL Item
Histoplasmosis (Histoplasmosis)
CL Item
Zygomycota Not Otherwise Specified (Zygomycetes, NOS)
CL Item
Zygomycosis (Mucormycosis)
CL Item
Rhizopus (Rhizopus)
CL Item
Yeast Not Otherwise Specified (Yeast, NOS)
CL Item
Other Fungi (Other fungus)
CL Item
Pneumocystis Pneumonia (Pneumocystis (PCP / PJP))
CL Item
Suspected Fungal Infection (Suspected fungal infection)
Item
Specify organism names: (2nd Organism Name)
text
CL Item
Acinetobacter (Acinetobacter)
CL Item
Actinomyces (Actinomyces)
CL Item
Bacillus (Bacillus)
CL Item
Bacteroides (Bacteroides (gracillis, uniformis, vulgaris, other species))
CL Item
Bordetella Pertussis (Bordetella pertussis (whooping cough))
CL Item
Borrelia Burgdorferi (Borrelia (lyme disease))
CL Item
Moraxella Catarrhalis (Branhamella or Moraxella catarrhalis (other species))
CL Item
Campylobacter (Campylobacter (all species))
CL Item
Capnocytophaga (Capnocytophaga)
CL Item
Chlamydophila Pneumoniae (Chlamydia (pneumoniae))
CL Item
Other Chlamydia (Other chlamydia)
CL Item
Chlamydia Not Otherwise Specified (Chlamydia, NOS)
CL Item
Citrobacter (Citrobacter (freundii, other species))
CL Item
Clostridium (Clostridium (all species except difficile))
CL Item
Clostridium Difficile (Clostridium difficile)
CL Item
Corynebacterium Jeikeium (Corynebacterium (jeikeium))
CL Item
Corynebacterium (Corynebacterium (all non-diptheria species))
CL Item
Coxiella (Coxiella)
CL Item
Enterobacter (Enterobacter)
CL Item
Vancomycin Resistant Enterococcus (Enterococcus, vancomycin resistant (VRE))
CL Item
Enterococcus (Enterococcus (all species))
CL Item
Escherichia Coli (Escherichia (also E. coli))
CL Item
Pseudomonas Oryzihabitans (Flavimonas oryzihabitans)
CL Item
Flavobacterium (Flavobacterium)
CL Item
Fusobacterium (Fusobacterium)
CL Item
Haemophilus (Haemophilus (all species, including influenzae))
CL Item
Helicobacter Pylori (Helicobacter pylori)
CL Item
Klebsiella (Klebsiella)
CL Item
Lactobacillus (Lactobacillus (bulgaricus, acidophilus, other species))
CL Item
Legionella (Legionella)
CL Item
Leptospira (Leptospira)
CL Item
C76356 (Leptotrichia buccalis)
CL Item
Leuconostoc (Leuconostoc (all species))
CL Item
Listeria (Listeria)
CL Item
Methylobacterium (Methylobacterium)
CL Item
Micrococcus Not Otherwise Specified (Micrococcus, NOS)
CL Item
Mycobacterium Avium Complex (Mycobacterium avium - intracellulare (MAC, MAI))
CL Item
Mycobacterium Species (Mycobacterium species (cheloneae, fortuitum, haemophilum, kansasii, mucogenicum))
CL Item
Mycobacterium Tuberculosis (Mycobacterium tuberculosis (tuberculosis, Koch bacillus))
CL Item
Other Mycobacterium (Other mycobacterium)
CL Item
Mycobacterium Not Otherwise Specified (Mycobacterium, NOS)
CL Item
Mycoplasma (Mycoplasma)
CL Item
Neisseria (Neisseria (gonorrhoeae, meningitidis, other species))
CL Item
Nocardia (Nocardia)
CL Item
Pasteurella Multocida (Pasteurella multocida)
CL Item
Propionibacterium Acnes (Propionibacterium (acnes, avidum, granulosum, other species))
CL Item
Proteus (Proteus)
CL Item
Pseudomonas (Pseudomonas (all species except cepacia & maltophilia))
CL Item
Burkholderia Cepacia (Pseudomonas or Burkholder cepacia)
CL Item
Stenotrophomonas Maltophilia (Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia)
CL Item
Rhodococcus (Rhodococcus)
CL Item
Rickettsia (Rickettsia)
CL Item
Salmonella (Salmonella (all species))
CL Item
Serratia Marcescens (Serratia marcescens)
CL Item
Shigella (Shigella)
CL Item
Staphylococcus Coag Negative (Staphylococcus, coagulase negative)
CL Item
Staphylococcus Aureus (Staphylococcus aureus)
CL Item
Streptococcus Not Otherwise Specified (Staphylococcus, NOS)
CL Item
Rothia Mucilaginosa (Stomatococcus mucilaginosis)
CL Item
Streptococcus (Streptococcus (all species except Enterococcus))
CL Item
Streptococcus Pneumoniae (Streptococcus pneumoniae)
CL Item
Treponema (Treponema (syphilis))
CL Item
Vibrio (Vibrio (all species))
CL Item
Multiple Bacteria (Multiple bacteria at a single site)
CL Item
Other Bacteria (Other bacteria)
CL Item
Suspected Atypical Bacteria Infection (Suspected atypical bacterial infection)
CL Item
Suspected Bacteria Infection (Suspected bacterial infection)
CL Item
Candida Not Otherwise Specified (Candida, NOS)
CL Item
Candida Albicans (Candida albicans)
CL Item
Pichia Guilliermondii (Candida guillermondi)
CL Item
Issatchenkia Orientalis (Candida krusei)
CL Item
Clavispora Lusitaniae (Candida lusitaniae)
CL Item
Candida Parapsilosis (Candida parapsilosis)
CL Item
Candida Tropicalis (Candida tropicalis)
CL Item
Candida Glabrata (Candida (Torulopsis) glabrata)
CL Item
Other Candida (Other Candida)
CL Item
Aspergillus Not Otherwise Specified (Aspergillus, NOS)
CL Item
Aspergillus Flavus (Aspergillus flavus)
CL Item
Aspergillus Fumigatus (Aspergillus fumigatus)
CL Item
Aspergillus Niger (Aspergillus niger)
CL Item
Other Aspergillus (Other Aspergillus)
CL Item
Cryptococcosis (Cryptococcosus species)
CL Item
Fusarium (Fusarium species)
CL Item
Histoplasmosis (Histoplasmosis)
CL Item
Zygomycota Not Otherwise Specified (Zygomycetes, NOS)
CL Item
Zygomycosis (Mucormycosis)
CL Item
Rhizopus (Rhizopus)
CL Item
Yeast Not Otherwise Specified (Yeast, NOS)
CL Item
Other Fungi (Other fungus)
CL Item
Pneumocystis Pneumonia (Pneumocystis (PCP / PJP))
CL Item
Suspected Fungal Infection (Suspected fungal infection)
Item
Specify organism names: (3rd Organism Name)
text
CL Item
Acinetobacter (Acinetobacter)
CL Item
Actinomyces (Actinomyces)
CL Item
Bacillus (Bacillus)
CL Item
Bacteroides (Bacteroides (gracillis, uniformis, vulgaris, other species))
CL Item
Bordetella Pertussis (Bordetella pertussis (whooping cough))
CL Item
Borrelia Burgdorferi (Borrelia (lyme disease))
CL Item
Moraxella Catarrhalis (Branhamella or Moraxella catarrhalis (other species))
CL Item
Campylobacter (Campylobacter (all species))
CL Item
Capnocytophaga (Capnocytophaga)
CL Item
Chlamydophila Pneumoniae (Chlamydia (pneumoniae))
CL Item
Other Chlamydia (Other chlamydia)
CL Item
Chlamydia Not Otherwise Specified (Chlamydia, NOS)
CL Item
Citrobacter (Citrobacter (freundii, other species))
CL Item
Clostridium (Clostridium (all species except difficile))
CL Item
Clostridium Difficile (Clostridium difficile)
CL Item
Corynebacterium Jeikeium (Corynebacterium (jeikeium))
CL Item
Corynebacterium (Corynebacterium (all non-diptheria species))
CL Item
Coxiella (Coxiella)
CL Item
Enterobacter (Enterobacter)
CL Item
Vancomycin Resistant Enterococcus (Enterococcus, vancomycin resistant (VRE))
CL Item
Enterococcus (Enterococcus (all species))
CL Item
Escherichia Coli (Escherichia (also E. coli))
CL Item
Pseudomonas Oryzihabitans (Flavimonas oryzihabitans)
CL Item
Flavobacterium (Flavobacterium)
CL Item
Fusobacterium (Fusobacterium)
CL Item
Haemophilus (Haemophilus (all species, including influenzae))
CL Item
Helicobacter Pylori (Helicobacter pylori)
CL Item
Klebsiella (Klebsiella)
CL Item
Lactobacillus (Lactobacillus (bulgaricus, acidophilus, other species))
CL Item
Legionella (Legionella)
CL Item
Leptospira (Leptospira)
CL Item
C76356 (Leptotrichia buccalis)
CL Item
Leuconostoc (Leuconostoc (all species))
CL Item
Listeria (Listeria)
CL Item
Methylobacterium (Methylobacterium)
CL Item
Micrococcus Not Otherwise Specified (Micrococcus, NOS)
CL Item
Mycobacterium Avium Complex (Mycobacterium avium - intracellulare (MAC, MAI))
CL Item
Mycobacterium Species (Mycobacterium species (cheloneae, fortuitum, haemophilum, kansasii, mucogenicum))
CL Item
Mycobacterium Tuberculosis (Mycobacterium tuberculosis (tuberculosis, Koch bacillus))
CL Item
Other Mycobacterium (Other mycobacterium)
CL Item
Mycobacterium Not Otherwise Specified (Mycobacterium, NOS)
CL Item
Mycoplasma (Mycoplasma)
CL Item
Neisseria (Neisseria (gonorrhoeae, meningitidis, other species))
CL Item
Nocardia (Nocardia)
CL Item
Pasteurella Multocida (Pasteurella multocida)
CL Item
Propionibacterium Acnes (Propionibacterium (acnes, avidum, granulosum, other species))
CL Item
Proteus (Proteus)
CL Item
Pseudomonas (Pseudomonas (all species except cepacia & maltophilia))
CL Item
Burkholderia Cepacia (Pseudomonas or Burkholder cepacia)
CL Item
Stenotrophomonas Maltophilia (Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia)
CL Item
Rhodococcus (Rhodococcus)
CL Item
Rickettsia (Rickettsia)
CL Item
Salmonella (Salmonella (all species))
CL Item
Serratia Marcescens (Serratia marcescens)
CL Item
Shigella (Shigella)
CL Item
Staphylococcus Coag Negative (Staphylococcus, coagulase negative)
CL Item
Staphylococcus Aureus (Staphylococcus aureus)
CL Item
Streptococcus Not Otherwise Specified (Staphylococcus, NOS)
CL Item
Rothia Mucilaginosa (Stomatococcus mucilaginosis)
CL Item
Streptococcus (Streptococcus (all species except Enterococcus))
CL Item
Streptococcus Pneumoniae (Streptococcus pneumoniae)
CL Item
Treponema (Treponema (syphilis))
CL Item
Vibrio (Vibrio (all species))
CL Item
Multiple Bacteria (Multiple bacteria at a single site)
CL Item
Other Bacteria (Other bacteria)
CL Item
Suspected Atypical Bacteria Infection (Suspected atypical bacterial infection)
CL Item
Suspected Bacteria Infection (Suspected bacterial infection)
CL Item
Candida Not Otherwise Specified (Candida, NOS)
CL Item
Candida Albicans (Candida albicans)
CL Item
Pichia Guilliermondii (Candida guillermondi)
CL Item
Issatchenkia Orientalis (Candida krusei)
CL Item
Clavispora Lusitaniae (Candida lusitaniae)
CL Item
Candida Parapsilosis (Candida parapsilosis)
CL Item
Candida Tropicalis (Candida tropicalis)
CL Item
Candida Glabrata (Candida (Torulopsis) glabrata)
CL Item
Other Candida (Other Candida)
CL Item
Aspergillus Not Otherwise Specified (Aspergillus, NOS)
CL Item
Aspergillus Flavus (Aspergillus flavus)
CL Item
Aspergillus Fumigatus (Aspergillus fumigatus)
CL Item
Aspergillus Niger (Aspergillus niger)
CL Item
Other Aspergillus (Other Aspergillus)
CL Item
Cryptococcosis (Cryptococcosus species)
CL Item
Fusarium (Fusarium species)
CL Item
Histoplasmosis (Histoplasmosis)
CL Item
Zygomycota Not Otherwise Specified (Zygomycetes, NOS)
CL Item
Zygomycosis (Mucormycosis)
CL Item
Rhizopus (Rhizopus)
CL Item
Yeast Not Otherwise Specified (Yeast, NOS)
CL Item
Other Fungi (Other fungus)
CL Item
Pneumocystis Pneumonia (Pneumocystis (PCP / PJP))
CL Item
Suspected Fungal Infection (Suspected fungal infection)
Item
Specify organism names: (4th Organism Name)
text
CL Item
Acinetobacter (Acinetobacter)
CL Item
Actinomyces (Actinomyces)
CL Item
Bacillus (Bacillus)
CL Item
Bacteroides (Bacteroides (gracillis, uniformis, vulgaris, other species))
CL Item
Bordetella Pertussis (Bordetella pertussis (whooping cough))
CL Item
Borrelia Burgdorferi (Borrelia (lyme disease))
CL Item
Moraxella Catarrhalis (Branhamella or Moraxella catarrhalis (other species))
CL Item
Campylobacter (Campylobacter (all species))
CL Item
Capnocytophaga (Capnocytophaga)
CL Item
Chlamydophila Pneumoniae (Chlamydia (pneumoniae))
CL Item
Other Chlamydia (Other chlamydia)
CL Item
Chlamydia Not Otherwise Specified (Chlamydia, NOS)
CL Item
Citrobacter (Citrobacter (freundii, other species))
CL Item
Clostridium (Clostridium (all species except difficile))
CL Item
Clostridium Difficile (Clostridium difficile)
CL Item
Corynebacterium Jeikeium (Corynebacterium (jeikeium))
CL Item
Corynebacterium (Corynebacterium (all non-diptheria species))
CL Item
Coxiella (Coxiella)
CL Item
Enterobacter (Enterobacter)
CL Item
Vancomycin Resistant Enterococcus (Enterococcus, vancomycin resistant (VRE))
CL Item
Enterococcus (Enterococcus (all species))
CL Item
Escherichia Coli (Escherichia (also E. coli))
CL Item
Pseudomonas Oryzihabitans (Flavimonas oryzihabitans)
CL Item
Flavobacterium (Flavobacterium)
CL Item
Fusobacterium (Fusobacterium)
CL Item
Haemophilus (Haemophilus (all species, including influenzae))
CL Item
Helicobacter Pylori (Helicobacter pylori)
CL Item
Klebsiella (Klebsiella)
CL Item
Lactobacillus (Lactobacillus (bulgaricus, acidophilus, other species))
CL Item
Legionella (Legionella)
CL Item
Leptospira (Leptospira)
CL Item
C76356 (Leptotrichia buccalis)
CL Item
Leuconostoc (Leuconostoc (all species))
CL Item
Listeria (Listeria)
CL Item
Methylobacterium (Methylobacterium)
CL Item
Micrococcus Not Otherwise Specified (Micrococcus, NOS)
CL Item
Mycobacterium Avium Complex (Mycobacterium avium - intracellulare (MAC, MAI))
CL Item
Mycobacterium Species (Mycobacterium species (cheloneae, fortuitum, haemophilum, kansasii, mucogenicum))
CL Item
Mycobacterium Tuberculosis (Mycobacterium tuberculosis (tuberculosis, Koch bacillus))
CL Item
Other Mycobacterium (Other mycobacterium)
CL Item
Mycobacterium Not Otherwise Specified (Mycobacterium, NOS)
CL Item
Mycoplasma (Mycoplasma)
CL Item
Neisseria (Neisseria (gonorrhoeae, meningitidis, other species))
CL Item
Nocardia (Nocardia)
CL Item
Pasteurella Multocida (Pasteurella multocida)
CL Item
Propionibacterium Acnes (Propionibacterium (acnes, avidum, granulosum, other species))
CL Item
Proteus (Proteus)
CL Item
Pseudomonas (Pseudomonas (all species except cepacia & maltophilia))
CL Item
Burkholderia Cepacia (Pseudomonas or Burkholder cepacia)
CL Item
Stenotrophomonas Maltophilia (Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia)
CL Item
Rhodococcus (Rhodococcus)
CL Item
Rickettsia (Rickettsia)
CL Item
Salmonella (Salmonella (all species))
CL Item
Serratia Marcescens (Serratia marcescens)
CL Item
Shigella (Shigella)
CL Item
Staphylococcus Coag Negative (Staphylococcus, coagulase negative)
CL Item
Staphylococcus Aureus (Staphylococcus aureus)
CL Item
Streptococcus Not Otherwise Specified (Staphylococcus, NOS)
CL Item
Rothia Mucilaginosa (Stomatococcus mucilaginosis)
CL Item
Streptococcus (Streptococcus (all species except Enterococcus))
CL Item
Streptococcus Pneumoniae (Streptococcus pneumoniae)
CL Item
Treponema (Treponema (syphilis))
CL Item
Vibrio (Vibrio (all species))
CL Item
Multiple Bacteria (Multiple bacteria at a single site)
CL Item
Other Bacteria (Other bacteria)
CL Item
Suspected Atypical Bacteria Infection (Suspected atypical bacterial infection)
CL Item
Suspected Bacteria Infection (Suspected bacterial infection)
CL Item
Candida Not Otherwise Specified (Candida, NOS)
CL Item
Candida Albicans (Candida albicans)
CL Item
Pichia Guilliermondii (Candida guillermondi)
CL Item
Issatchenkia Orientalis (Candida krusei)
CL Item
Clavispora Lusitaniae (Candida lusitaniae)
CL Item
Candida Parapsilosis (Candida parapsilosis)
CL Item
Candida Tropicalis (Candida tropicalis)
CL Item
Candida Glabrata (Candida (Torulopsis) glabrata)
CL Item
Other Candida (Other Candida)
CL Item
Aspergillus Not Otherwise Specified (Aspergillus, NOS)
CL Item
Aspergillus Flavus (Aspergillus flavus)
CL Item
Aspergillus Fumigatus (Aspergillus fumigatus)
CL Item
Aspergillus Niger (Aspergillus niger)
CL Item
Other Aspergillus (Other Aspergillus)
CL Item
Cryptococcosis (Cryptococcosus species)
CL Item
Fusarium (Fusarium species)
CL Item
Histoplasmosis (Histoplasmosis)
CL Item
Zygomycota Not Otherwise Specified (Zygomycetes, NOS)
CL Item
Zygomycosis (Mucormycosis)
CL Item
Rhizopus (Rhizopus)
CL Item
Yeast Not Otherwise Specified (Yeast, NOS)
CL Item
Other Fungi (Other fungus)
CL Item
Pneumocystis Pneumonia (Pneumocystis (PCP / PJP))
CL Item
Suspected Fungal Infection (Suspected fungal infection)
Item
Specify organism names: (5th Organism Name)
text
CL Item
Acinetobacter (Acinetobacter)
CL Item
Actinomyces (Actinomyces)
CL Item
Bacillus (Bacillus)
CL Item
Bacteroides (Bacteroides (gracillis, uniformis, vulgaris, other species))
CL Item
Bordetella Pertussis (Bordetella pertussis (whooping cough))
CL Item
Borrelia Burgdorferi (Borrelia (lyme disease))
CL Item
Moraxella Catarrhalis (Branhamella or Moraxella catarrhalis (other species))
CL Item
Campylobacter (Campylobacter (all species))
CL Item
Capnocytophaga (Capnocytophaga)
CL Item
Chlamydophila Pneumoniae (Chlamydia (pneumoniae))
CL Item
Other Chlamydia (Other chlamydia)
CL Item
Chlamydia Not Otherwise Specified (Chlamydia, NOS)
CL Item
Citrobacter (Citrobacter (freundii, other species))
CL Item
Clostridium (Clostridium (all species except difficile))
CL Item
Clostridium Difficile (Clostridium difficile)
CL Item
Corynebacterium Jeikeium (Corynebacterium (jeikeium))
CL Item
Corynebacterium (Corynebacterium (all non-diptheria species))
CL Item
Coxiella (Coxiella)
CL Item
Enterobacter (Enterobacter)
CL Item
Vancomycin Resistant Enterococcus (Enterococcus, vancomycin resistant (VRE))
CL Item
Enterococcus (Enterococcus (all species))
CL Item
Escherichia Coli (Escherichia (also E. coli))
CL Item
Pseudomonas Oryzihabitans (Flavimonas oryzihabitans)
CL Item
Flavobacterium (Flavobacterium)
CL Item
Fusobacterium (Fusobacterium)
CL Item
Haemophilus (Haemophilus (all species, including influenzae))
CL Item
Helicobacter Pylori (Helicobacter pylori)
CL Item
Klebsiella (Klebsiella)
CL Item
Lactobacillus (Lactobacillus (bulgaricus, acidophilus, other species))
CL Item
Legionella (Legionella)
CL Item
Leptospira (Leptospira)
CL Item
C76356 (Leptotrichia buccalis)
CL Item
Leuconostoc (Leuconostoc (all species))
CL Item
Listeria (Listeria)
CL Item
Methylobacterium (Methylobacterium)
CL Item
Micrococcus Not Otherwise Specified (Micrococcus, NOS)
CL Item
Mycobacterium Avium Complex (Mycobacterium avium - intracellulare (MAC, MAI))
CL Item
Mycobacterium Species (Mycobacterium species (cheloneae, fortuitum, haemophilum, kansasii, mucogenicum))
CL Item
Mycobacterium Tuberculosis (Mycobacterium tuberculosis (tuberculosis, Koch bacillus))
CL Item
Other Mycobacterium (Other mycobacterium)
CL Item
Mycobacterium Not Otherwise Specified (Mycobacterium, NOS)
CL Item
Mycoplasma (Mycoplasma)
CL Item
Neisseria (Neisseria (gonorrhoeae, meningitidis, other species))
CL Item
Nocardia (Nocardia)
CL Item
Pasteurella Multocida (Pasteurella multocida)
CL Item
Propionibacterium Acnes (Propionibacterium (acnes, avidum, granulosum, other species))
CL Item
Proteus (Proteus)
CL Item
Pseudomonas (Pseudomonas (all species except cepacia & maltophilia))
CL Item
Burkholderia Cepacia (Pseudomonas or Burkholder cepacia)
CL Item
Stenotrophomonas Maltophilia (Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia)
CL Item
Rhodococcus (Rhodococcus)
CL Item
Rickettsia (Rickettsia)
CL Item
Salmonella (Salmonella (all species))
CL Item
Serratia Marcescens (Serratia marcescens)
CL Item
Shigella (Shigella)
CL Item
Staphylococcus Coag Negative (Staphylococcus, coagulase negative)
CL Item
Staphylococcus Aureus (Staphylococcus aureus)
CL Item
Streptococcus Not Otherwise Specified (Staphylococcus, NOS)
CL Item
Rothia Mucilaginosa (Stomatococcus mucilaginosis)
CL Item
Streptococcus (Streptococcus (all species except Enterococcus))
CL Item
Streptococcus Pneumoniae (Streptococcus pneumoniae)
CL Item
Treponema (Treponema (syphilis))
CL Item
Vibrio (Vibrio (all species))
CL Item
Multiple Bacteria (Multiple bacteria at a single site)
CL Item
Other Bacteria (Other bacteria)
CL Item
Suspected Atypical Bacteria Infection (Suspected atypical bacterial infection)
CL Item
Suspected Bacteria Infection (Suspected bacterial infection)
CL Item
Candida Not Otherwise Specified (Candida, NOS)
CL Item
Candida Albicans (Candida albicans)
CL Item
Pichia Guilliermondii (Candida guillermondi)
CL Item
Issatchenkia Orientalis (Candida krusei)
CL Item
Clavispora Lusitaniae (Candida lusitaniae)
CL Item
Candida Parapsilosis (Candida parapsilosis)
CL Item
Candida Tropicalis (Candida tropicalis)
CL Item
Candida Glabrata (Candida (Torulopsis) glabrata)
CL Item
Other Candida (Other Candida)
CL Item
Aspergillus Not Otherwise Specified (Aspergillus, NOS)
CL Item
Aspergillus Flavus (Aspergillus flavus)
CL Item
Aspergillus Fumigatus (Aspergillus fumigatus)
CL Item
Aspergillus Niger (Aspergillus niger)
CL Item
Other Aspergillus (Other Aspergillus)
CL Item
Cryptococcosis (Cryptococcosus species)
CL Item
Fusarium (Fusarium species)
CL Item
Histoplasmosis (Histoplasmosis)
CL Item
Zygomycota Not Otherwise Specified (Zygomycetes, NOS)
CL Item
Zygomycosis (Mucormycosis)
CL Item
Rhizopus (Rhizopus)
CL Item
Yeast Not Otherwise Specified (Yeast, NOS)
CL Item
Other Fungi (Other fungus)
CL Item
Pneumocystis Pneumonia (Pneumocystis (PCP / PJP))
CL Item
Suspected Fungal Infection (Suspected fungal infection)
Item
Specify organism names: (6th Organism Name)
text
CL Item
Acinetobacter (Acinetobacter)
CL Item
Actinomyces (Actinomyces)
CL Item
Bacillus (Bacillus)
CL Item
Bacteroides (Bacteroides (gracillis, uniformis, vulgaris, other species))
CL Item
Bordetella Pertussis (Bordetella pertussis (whooping cough))
CL Item
Borrelia Burgdorferi (Borrelia (lyme disease))
CL Item
Moraxella Catarrhalis (Branhamella or Moraxella catarrhalis (other species))
CL Item
Campylobacter (Campylobacter (all species))
CL Item
Capnocytophaga (Capnocytophaga)
CL Item
Chlamydophila Pneumoniae (Chlamydia (pneumoniae))
CL Item
Other Chlamydia (Other chlamydia)
CL Item
Chlamydia Not Otherwise Specified (Chlamydia, NOS)
CL Item
Citrobacter (Citrobacter (freundii, other species))
CL Item
Clostridium (Clostridium (all species except difficile))
CL Item
Clostridium Difficile (Clostridium difficile)
CL Item
Corynebacterium Jeikeium (Corynebacterium (jeikeium))
CL Item
Corynebacterium (Corynebacterium (all non-diptheria species))
CL Item
Coxiella (Coxiella)
CL Item
Enterobacter (Enterobacter)
CL Item
Vancomycin Resistant Enterococcus (Enterococcus, vancomycin resistant (VRE))
CL Item
Enterococcus (Enterococcus (all species))
CL Item
Escherichia Coli (Escherichia (also E. coli))
CL Item
Pseudomonas Oryzihabitans (Flavimonas oryzihabitans)
CL Item
Flavobacterium (Flavobacterium)
CL Item
Fusobacterium (Fusobacterium)
CL Item
Haemophilus (Haemophilus (all species, including influenzae))
CL Item
Helicobacter Pylori (Helicobacter pylori)
CL Item
Klebsiella (Klebsiella)
CL Item
Lactobacillus (Lactobacillus (bulgaricus, acidophilus, other species))
CL Item
Legionella (Legionella)
CL Item
Leptospira (Leptospira)
CL Item
C76356 (Leptotrichia buccalis)
CL Item
Leuconostoc (Leuconostoc (all species))
CL Item
Listeria (Listeria)
CL Item
Methylobacterium (Methylobacterium)
CL Item
Micrococcus Not Otherwise Specified (Micrococcus, NOS)
CL Item
Mycobacterium Avium Complex (Mycobacterium avium - intracellulare (MAC, MAI))
CL Item
Mycobacterium Species (Mycobacterium species (cheloneae, fortuitum, haemophilum, kansasii, mucogenicum))
CL Item
Mycobacterium Tuberculosis (Mycobacterium tuberculosis (tuberculosis, Koch bacillus))
CL Item
Other Mycobacterium (Other mycobacterium)
CL Item
Mycobacterium Not Otherwise Specified (Mycobacterium, NOS)
CL Item
Mycoplasma (Mycoplasma)
CL Item
Neisseria (Neisseria (gonorrhoeae, meningitidis, other species))
CL Item
Nocardia (Nocardia)
CL Item
Pasteurella Multocida (Pasteurella multocida)
CL Item
Propionibacterium Acnes (Propionibacterium (acnes, avidum, granulosum, other species))
CL Item
Proteus (Proteus)
CL Item
Pseudomonas (Pseudomonas (all species except cepacia & maltophilia))
CL Item
Burkholderia Cepacia (Pseudomonas or Burkholder cepacia)
CL Item
Stenotrophomonas Maltophilia (Pseudomonas or Stenotrophomonas or Xanthomonas maltophilia)
CL Item
Rhodococcus (Rhodococcus)
CL Item
Rickettsia (Rickettsia)
CL Item
Salmonella (Salmonella (all species))
CL Item
Serratia Marcescens (Serratia marcescens)
CL Item
Shigella (Shigella)
CL Item
Staphylococcus Coag Negative (Staphylococcus, coagulase negative)
CL Item
Staphylococcus Aureus (Staphylococcus aureus)
CL Item
Streptococcus Not Otherwise Specified (Staphylococcus, NOS)
CL Item
Rothia Mucilaginosa (Stomatococcus mucilaginosis)
CL Item
Streptococcus (Streptococcus (all species except Enterococcus))
CL Item
Streptococcus Pneumoniae (Streptococcus pneumoniae)
CL Item
Treponema (Treponema (syphilis))
CL Item
Vibrio (Vibrio (all species))
CL Item
Multiple Bacteria (Multiple bacteria at a single site)
CL Item
Other Bacteria (Other bacteria)
CL Item
Suspected Atypical Bacteria Infection (Suspected atypical bacterial infection)
CL Item
Suspected Bacteria Infection (Suspected bacterial infection)
CL Item
Candida Not Otherwise Specified (Candida, NOS)
CL Item
Candida Albicans (Candida albicans)
CL Item
Pichia Guilliermondii (Candida guillermondi)
CL Item
Issatchenkia Orientalis (Candida krusei)
CL Item
Clavispora Lusitaniae (Candida lusitaniae)
CL Item
Candida Parapsilosis (Candida parapsilosis)
CL Item
Candida Tropicalis (Candida tropicalis)
CL Item
Candida Glabrata (Candida (Torulopsis) glabrata)
CL Item
Other Candida (Other Candida)
CL Item
Aspergillus Not Otherwise Specified (Aspergillus, NOS)
CL Item
Aspergillus Flavus (Aspergillus flavus)
CL Item
Aspergillus Fumigatus (Aspergillus fumigatus)
CL Item
Aspergillus Niger (Aspergillus niger)
CL Item
Other Aspergillus (Other Aspergillus)
CL Item
Cryptococcosis (Cryptococcosus species)
CL Item
Fusarium (Fusarium species)
CL Item
Histoplasmosis (Histoplasmosis)
CL Item
Zygomycota Not Otherwise Specified (Zygomycetes, NOS)
CL Item
Zygomycosis (Mucormycosis)
CL Item
Rhizopus (Rhizopus)
CL Item
Yeast Not Otherwise Specified (Yeast, NOS)
CL Item
Other Fungi (Other fungus)
CL Item
Pneumocystis Pneumonia (Pneumocystis (PCP / PJP))
CL Item
Suspected Fungal Infection (Suspected fungal infection)
PriorInfusionProcedureCultureProcedureBacteriaFungiInfectiousDisorderOtherOrganismSpecify
Item
If codes 198, 209, 219, or 259, specify organism: (Answer only if the value for 2784429, 2784431,2784433,2784435,2784437 and 2784439 is "Other bacteria, specify","Other Candida, specify",Other Aspergillus, specify" or "Other fungus, specify".)
text
Item
Was more than one product infused? (e.g., marrow and PBSC,PBSC and cord blood, two different cords, etc.)
text
Code List
Was more than one product infused? (e.g., marrow and PBSC,PBSC and cord blood, two different cords, etc.)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Was the product infusion described on this insert intended to produce hematopoietic engraftment?
text
Code List
Was the product infusion described on this insert intended to produce hematopoietic engraftment?
CL Item
Yes (Yes)
CL Item
No (No)
MultipleHematopoieticStemCellGraftInfusionProcedureDate
Item
Date of this product infusion:
date
HematopoieticStemCellGraftInfusionProcedureBeginTime
Item
Time product infusion initiated (24-hour clock):
time
Item
Is it the standard time or daylight savings time?
text
CL Item
Standard Time (Standard time)
CL Item
Daylight Savings Time (Daylight Savings Time)
HematopoieticStemCellGraftInfusionProcedureEndTime
Item
Time product infusion completed (24-hour clock):
time
Item
Is it the standard time or daylight savings time?
text
CL Item
Standard Time (Standard time)
CL Item
Daylight Savings Time (Daylight Savings Time)
HematopoieticStemCellGraftCombinedAdditiveInfusionProcedureTotalVolumeValue
Item
Total volume of product plus additives infused: (One decimal place with Unit of Measure "ml")
double
Item
Specify the route of product infusion:
text
CL Item
Intravenous Route Of Administration (Intravenous)
CL Item
Intramedullary Route Of Administration (Intramedullary)
CL Item
Intraperitoneal Route Of Administration (Intraperitoneal)
CL Item
Other Route Of Administration (Other route of infusion)
HematopoieticStemCellGraftInfusionProcedureOtherRouteofAdministrationTherapiesSpecify
Item
Specify route of infusion:
text
Item
Did the volume of infused product include any added agents?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
What kind of additives are included in volume of infused product?
text
CL Item
Acid-citrate-dextrose (Acid-Citrate-Dextrose (ACD))
CL Item
Albumin (Albumin)
CL Item
Antibiotic (Antibiotic)
CL Item
Dextran Sulfate Sodium (Dextran)
CL Item
Heparin (Heparin)
CL Item
Other (Other)
Item
Were particular additives included in volume of infused product?
text
CL Item
Yes (Yes)
CL Item
No (No)
WithinHematopoieticStemCellGraftInfusionProcedureOtherAdditiveAdministeredTherapiesSpecify
Item
Specify agent: (Answer only if the value for 2740356 is "Other")
text
Item
Was the entire volume of product infused?
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Destruction (Discarded)
CL Item
Cryopreservation (Cryopreserved for future use)
CL Item
Other Endpoints (Other fate)
ReservationPartEndPointSpecifyText
Item
Specify: (Answer only if the value for 2769592 is "Other fate")
text
Item
Were there any adverse events or incidents associated with the stem cell infusion? (The question refers to all stem cell products except for autologous marrow or autologous PBSC products.)
text
Code List
Were there any adverse events or incidents associated with the stem cell infusion? (The question refers to all stem cell products except for autologous marrow or autologous PBSC products.)
CL Item
Yes (Yes)
CL Item
No (No)
Item
What type of Adverse Events associated with the stem cell infusion?
text
CL Item
Bradycardia (Brachycardia)
CL Item
Chest Pain (Chest tightness/pain)
CL Item
At Infusion Time Chills (Chills at time of infusion)
CL Item
Fever <= 103 F Within 24 Hours Of Infusion (Fever less than or equal to 103 F within 24 hours of infusion)
CL Item
Fever > 103 F Within 24 Hours Of Infusion (Fever greater than 103 F within 24 hours of infusion)
CL Item
Whole Hemoglobinuria (Gross hemoglobinuria)
CL Item
Headache (Headache)
CL Item
Urticaria (Hives)
CL Item
Hypertension (Hypertension)
CL Item
Hypotension (Hypotension)
CL Item
Required Oxygen Hypoxia (Hypoxia requiring oxygen(O2) support)
CL Item
Nausea (Nausea)
CL Item
Ctcae Grade 1 Rigors And Chills (Rigors, mild)
CL Item
Ctcae Grade 3 Rigors And Chills (Rigors, severe)
CL Item
Dyspnea (Shortness of breath(SOB))
CL Item
Tachycardia (Tachycardia)
CL Item
Vomiting (Vomiting)
CL Item
Other Expected Adverse Event (Other expected AE)
CL Item
Other Unexpected Adverse Event (Other unexpected AE)
Item
Did a particular stem cell infusion associated adverse event occur?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Did particular adverse events require medical intervention?
text
CL Item
Yes (Yes)
CL Item
No (No)
Item
Were particular adverse events resolved?
text
CL Item
Yes (Yes)
CL Item
No (No)
HematopoieticStemCellGraftInfusionProcedureOtherAdverseEventSpecify
Item
Specify (Answer only if the value for 2739534 is "Other expected AE" or "Other unexpected AE")
text
Item
In the Medical Director's judgement, was the adverse event a direct result of the infusion?
text
Code List
In the Medical Director's judgement, was the adverse event a direct result of the infusion?
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Relationship Regimen (Regimen related)
CL Item
Hematopoietic Stem Cell Transplant Reaction (Product reaction)
CL Item
Medication Reaction (Drug reaction)
CL Item
Other Diseases And Disorders (Other illness)
CL Item
Other Reason (Other reason)
AdverseEventOtherDiseaseorDisorderTherapiesSpecify
Item
Specify illness: (Answer only if the value for 2769598 is "Other illness")
text
AdverseEventOtherReasonTherapiesSpecify
Item
Specify reason: (Answer only if the value for 2769598 is "Other reason")
text
TransplantDonorBirthDate
Item
Donor date of birth:
date
CL Item
Date Unknown (date unknown)
MotherAgeValue
Item
Age of mother (approximate): (Cord blood unit only)
double
Item
What is the reason for the mother's missing age? (Cord blood unit only)
text
CL Item
Unknown Not Applicable (Unknown/not applicable)
HematopoieticStemCellTransplantationUmbilicalCordBloodTypeNotInstitution::NationalMarrowDonorProgramIdentifier
Item
Non-NMDP Cord Blood Unit (CBU) ID: (Cord blood unit only)
text
Item
Is the CBU ID number also the ICCBBA ISBT 128 number? (Cord blood unit only)
text
CL Item
Yes (Yes)
CL Item
No (No)
TissueBankingInstitutionName
Item
Name of cord blood bank providing CBU: (Cord blood unit only)
text
CL Item
Male (male)
CL Item
Female (female)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
CL Item
Not Applicable (Not Applicable)
TissueDonorPregnancyCount
Item
Specify number of pregnancies:
double
Item
What is the reason for the missing number of pregnancies?
text
CL Item
Unknown Not Applicable (Unknown/not applicable)
CL Item
Blood Group A Rh Positive Blood Group (A positive)
CL Item
Blood Group A Rh Negative Blood Group (A negative)
CL Item
Blood Group B Rh Positive Blood Group (B positive)
CL Item
Blood Group B Rh Negative Blood Group (B negative)
CL Item
Blood Group Ab Rh Positive Blood Group (AB positive)
CL Item
Blood Group Ab Rh Negative Blood Group (AB negative)
CL Item
Blood Group O Rh Positive Blood Group (O positive)
CL Item
Blood Group O Rh Negative Blood Group (O negative)
CL Item
Unknown (unknown)
Item
Did this donor have a central line placed?
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Not Applicable (Not Applicable)
Item
Specify the site of the central line placement:
text
CL Item
Femoral Vein (Femoral)
CL Item
Subclavian Vein (Subclavian)
CL Item
Internal Jugular Vein (Internal jugular)
CL Item
Other Anatomic Site (Other site)
TissueDonorCentralVenousAccessCatheterAnatomicSiteOtherSpecify
Item
Specify site: (Answer only if the value for 2769666 is "Other site")
text
CL Item
A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (Hispanic or Latino)
CL Item
A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)
CL Item
Could Not Be Determined Or Unsure (Unknown)
Item
Donor's race (Mark the groups in which the donor is a member. Check all that apply )
text
Code List
Donor's race (Mark the groups in which the donor is a member. Check all that apply )
CL Item
Eastern European (Eastern European)
CL Item
Mediterranean (Mediterranean)
CL Item
Middle Eastern (Middle Eastern)
CL Item
North Coast Of Africa (North Coast of Africa)
CL Item
North American (North American)
CL Item
Northern European (Northern European)
CL Item
Western European (Western European)
CL Item
White Caribbean (White Caribbean)
CL Item
White South Or Central American (White South or Central American)
CL Item
Other White (Other White)
CL Item
African (African (both parents born in Africa))
CL Item
African American (African American)
CL Item
African Caribbean (Black Caribbean)
CL Item
Black South Or Central American (Black South or Central American)
CL Item
Alaska Native (Alaskan Native or Aleut)
CL Item
American Indian (North American Indian)
CL Item
South Or Central American Indian (American Indian, South or Central America)
CL Item
Caribbean Indian (Caribbean Indian)
CL Item
South Asian (South Asian)
CL Item
Filipino (Filipino (Pilipino))
CL Item
Japanese (Japanese)
CL Item
Korean (Korean)
CL Item
Chinese (Chinese)
CL Item
Vietnamese (Vietnamese)
CL Item
Other South Asian (Other Southeast Asian)
CL Item
Guamanian (Guamanian)
CL Item
Hawaiian (Hawaiian)
CL Item
Samoan (Samoan)
CL Item
Other Native Hawaiian Or Other Pacific Islander (Other Pacific Islander)
CL Item
Response Declined (Declines to provide race)
CL Item
Unknown (Race unknown)
Item
What is the relationship of the donor to the recipient?
text
CL Item
Sibling (Sibling)
CL Item
Recipient Child (Recipient's child)
CL Item
Other Relative (Other relative)
CL Item
Unrelated (Unrelated)
Item
Specify the relationship of the donor to the recipient: (Answer only if the value for 2784447 is "Other relative")
text
Code List
Specify the relationship of the donor to the recipient: (Answer only if the value for 2784447 is "Other relative")
CL Item
Parent (Parent)
CL Item
Aunt (Aunt)
CL Item
Uncle (Uncle)
CL Item
Cousin (Cousin)
CL Item
Other Relative (Other relative)
TissueDonorOtherRecipientRelationshipText
Item
Specify relationship: (Answer only if the value for 2728852 is "Other relative")
text
Item
Was the donor / product tested for potentially transplantable genetic diseases?
text
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Unknown (Unknown)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
No (No)
TissueDonorGeneticTestingOtherDiseaseorDisorderSpecify
Item
Specify genetic disease: (Answer only if the value for 2772022 is "Yes")
text
Item
Was the donor hospitalized (inpatient) during or after the collection? (Question applies only to allogeneic non-NMDP donors)
text
Code List
Was the donor hospitalized (inpatient) during or after the collection? (Question applies only to allogeneic non-NMDP donors)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Did the donor experience any life-threatening complications during or after the collection? (Question applies only to allogeneic non-NMDP donors)
text
Code List
Did the donor experience any life-threatening complications during or after the collection? (Question applies only to allogeneic non-NMDP donors)
CL Item
Yes (Yes)
CL Item
No (No)
TissueDonorDuringOrAfterHematopoieticStemCellCollectionLifeThreateningorDisablingAdverseEventSpecify
Item
Specify complications: (Question applies only to allogeneic non-NMDP donors. Answer only if the value of CDE 2728986 is "Yes".)
text
Item
Did the donor receive blood transfusions as a result of the collection? (Question applies only to allogeneic non-NMDP donors)
text
Code List
Did the donor receive blood transfusions as a result of the collection? (Question applies only to allogeneic non-NMDP donors)
CL Item
Yes (Yes)
CL Item
No (No)
Item
Was the blood transfusion product autologous? (Question applies only to allogeneic non-NMDP donors )
text
Code List
Was the blood transfusion product autologous? (Question applies only to allogeneic non-NMDP donors )
CL Item
Yes (Yes)
CL Item
No (No)
BloodTransfusionAutologousUnitNumber
Item
Specify number of units: (For the autologous blood transfusion)
double
Item
Was the blood transfusion product allogeneic (homologous)? (Question applies only to allogeneic non-NMDP donors)
text
Code List
Was the blood transfusion product allogeneic (homologous)? (Question applies only to allogeneic non-NMDP donors)
CL Item
Yes (Yes)
CL Item
No (No)
BloodTransfusionAllogenicUnitNumber
Item
Specify number of units: (For the autologous blood transfusion)
double
Item
Did the donor die as a result of the collection? (Question applies only to allogeneic non-NMDP donors)
text
Code List
Did the donor die as a result of the collection? (Question applies only to allogeneic non-NMDP donors)
CL Item
Yes (Yes)
CL Item
No (No)
TissueDonorHematopoieticStemCellCollectionOutcomeDeathReasonSpecify
Item
Specify cause of death: (Question applies only to allogeneic non-NMDP donors)
text
Item
Did the recipient submit a research sample? (Related donors only)
text
CL Item
Yes (Yes)
CL Item
No (No)
RecipientResearchSpecimenIdentificationNumber
Item
Research sample recipient ID:
double
Item
Did the donor submit a research sample? (Related donors only)
text
CL Item
Yes (Yes)
CL Item
No (No)
TissueDonorResearchSpecimenIdentificationNumber
Item
Research sample donor ID: (Related donors only)
double
PersonGiven/FirstName
Item
First Name
text
PersonFamily/LastName
Item
Last Name
text
ContactPersonLocationTelephoneNumber
Item
Telephone number:
text
ContactPersonLocationFaxNumber
Item
Fax number:
text
PersonEmailAddressText
Item
E-mail address:
text