Demographics

*The timeline requirements for this form are as follows:
Assessment Time Frame: At the time of eligibility assessment.
Submission Time Frame: As soon as possible after eligibility criteria are assessed.

Date of Birth:
Enter the subject’s date of birth in DD/MMM/YYYY format or select from the calendar date picker.

If the date entered is a future date, a query will appear in the EDC.

Age at time of consent: [SYSTEM GENERATED]
Subject age is recorded as numeric up to three digits, derived from the Date of Birth provided above and the Date study ICF signed. If the Informed Consent case report form or ICF date field has not yet been completed, this field will not populate. This field requires no response from the study site and cannot be edited.

Sex Assigned at Birth:
Indicate the subject’s biological sex assigned at birth as male or female.

Race (select one or more options):

!At least one broad race category, Not otherwise specified, or Prefer not to answer must be selected. If a broad race category is selected (i.e., Asian), a detailed race option must be selected (i.e., Chinese).

It is recommended that subjects self-report race and ethnicity information. Indicate the subject’s race as one or more of the following:

Indigenous American

o Alaskan Native
o Indigenous Caribbean
o American South/Central American
o Indigenous North American
o Not otherwise specified Indigenous American

Asian

o Caribbean Indian
o Chinese
o Filipino
o Indian
o Japanese
o Korean
o Malaysian
o Mongolian
o Pakistani
o Taiwanese
o Thai
o Vietnamese
o Other Indian subcontinent
o Other Southeast Asian, specify
o Not otherwise specified Asian

Black or African

o African American
o Black Caribbean
o Black South or Central American
o East African
o South African
o West African
o Not otherwise specified Black/African

Hispanic/Latino

o Brazilian
o Caribbean Hispanic
o Cuban
o Mexican
o Puerto Rican
o South/Central American Hispanic
o Not otherwise specified Hispanic/Latino

Middle Eastern/North African

o Arab peninsula
o Central Asian
o East Mediterranean
o North African
o Not otherwise specified Middle Eastern/North African

Pacific Islander

o Melanesian
o Micronesian
o Native Hawaiian
o Polynesian
o Not otherwise specified Pacific Islander

White

o Eastern European
o Northern European
o Russian or former Soviet Union
o Southern European
o Western European
o White Caribbean
o White South or Central
o Not otherwise specified White

Jewish

o Ashkenazi
o Mizrahi
o Sephardi
o Not otherwise specified Jewish

Not otherwise specified

Prefer not to answer

CCG v1.0 | CRF v1.3

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CIBMTR® (Center for International Blood and Marrow Transplant Research) is a research collaboration between the Medical College of Wisconsin and NMDP.