Recipient Disease

*The timeline requirements for this form are as follows:
Assessment Time Frame: Within 45 days prior to the anticipated start of the conditioning regimen.
Submission Time Frame: Within 5 business days of collection.

Disease Classification

Date of diagnosis:
Report the date of the first pathological diagnosis (e.g., bone marrow or tissue biopsy) of the disease. Enter the date the sample was collected for examination. If the diagnosis was determined at an outside center, and no documentation of a pathological or laboratory assessment is available, the dictated date of diagnosis within a physician note may be reported. Do not report the date symptoms first appeared. Date can either be entered directly in the data field using the DD/MMM/YYYY format, or the calendar date picker can be used. This field allows for unknown dates, but not unknown months or years.

Specify the disease indication at diagnosis:
Report recipient disease from the following options:

• ALL
• AML
• MDS
• Other acute leukemia
• Chronic lymphocytic leukemia or Other Leukemia
• Myelodysplastic syndrome/ myeloproliferative neoplasm (MDS/MPN)
• Lymphoma
• Myeloproliferative neoplasm (MPN)

CCG v1.0 | CRF v1.3

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