Conditioning and Transplant Dates

*The timeline requirements for this form are as follows:
Assessment Time Frame: Baseline (0-21 days prior to first day of conditioning)
Submission Time Frame: Within 30 days after the date of transplant

Conditioning and transplant dates

CIMBTR Research ID (CRID):
The CIBMTR Research ID (CRID) is a unique identifier assigned when an individual is registered with the CIBMTR as receiving a cellular therapy, including hematopoietic stem cell transplant (HCT), treatment for marrow toxic injuries, and certain non-cellular therapies. The CRID is generated using the CIBMTR Unique ID Assignment Form (Form 2804) and must be completed for all HCT recipients. Contact your local CIBMTR data manager for assistance on how to complete this form. Enter the subject’s CRID.

Primary disease for which the HCT was performed
Report the primary disease for which the HCT was performed from the options available

• Acute myelogenous leukemia (AML or ANLL)
• Acute lymphoblastic leukemia (ALL)
• Acute leukemia of ambiguous lineage and other myeloid neoplasms
• Chronic myelogenous leukemia (CML)
• Myelodysplastic (MDS) / myeloproliferative (MPN) diseases (If subject has transformed to AML, indicate AML as the primary disease)
• Other leukemia (includes CLL)
• Hodgkin lymphoma
• Non-Hodgkin lymphoma
• Multiple myeloma / plasma cell disorder
• Other hematological malignancy, specify
  

If the hematological malignancy is not available in options provided, indicate “other hematological malignancy, specify” and enter the hematological malignancy in the space available.

Conditioning start date:
Enter the date the conditioning regimen began in DD/MMM/YYYY format. This should be the first date chemotherapy or radiation included in the conditioning regimen was administered.

Transplant date:
Enter the date of transplant in DD/MMM/YYYY format.

*Note: This should be the date infusion started or the first date of infusion if infusion extended across multiple days. Ensure the “transplant date” matches the “planned HCT date” reported in the 2814: Indication for CRID Assignment form. If the date of infusion changes, this form should be updated.

Donor Type:
Select the type of donor from the options available:

• HLA-identical sibling (may include non-monoygotic twin)
• Unrelated donor
• HLA-mismatched relative
  

Product Type (check all that apply):
Select the type of product(s) from the options available:

• Bone marrow
• PBSC
• Umbilical cord blood (CBU)
  

CCG v.4.0 | CRF v.3.0

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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.