Inclusion criteria
Patient is 60 years old or greater at time of enrollment:
Per protocol, the inclusion criteria for this study requires patients to be 60 years old or greater at the time of informed consent. If “No” is indicated and the form is processed, the patient will not be enrolled in the study.
Patient has hematological malignancy as an indication for allogeneic transplantation:
Indicate if the patient has a hematological malignancy as an indication for allogeneic transplant. If “No” is indicated and the form is processed, the patient will not be enrolled in the study.
Patient is eligible for allogeneic transplantation based on institutional standards:
Indicate if the patient is eligible for allogeneic transplantation based on the site’s institutional standards. If “No” is indicated and the form is processed, the patient will not be enrolled in the study.
Patient has first allogeneic transplant planned (any conditioning regimen and allogeneic donor is acceptable):
Indicate if the patient has their first allogeneic transplant planned. If “No” is indicated and the form is processed, the patient will not be enrolled in the study.
Future planned conditioning start date
Report planned date the conditioning regimen prior to transplant is expected to start. Enter the date in DD/MMM/YYYY format. If a planned conditioning start date is unknown, it is appropriate to provide an approximate date (e.g., the middle of the month could be approximated as May 15, 2020)
Future planned transplant date
Report the planned date of the transplant. Enter the date in DD/MMM/YYYY format. If a transplant date is unknown, it is appropriate to provide an approximate date (e.g., the middle of the month could be approximated as May 15, 2020)
Patient is able to speak and read English OR Spanish and Mandarin will be acceptable when sites have the ability to perform healthcare provider tests in those languages.
Indicate if the patient is able to speak and read English. If the patient is able to speak Spanish or Mandarin, indicate if the site will have the ability to perform healthcare provider tests in those languages. If “No” is indicated and the form is processed, the patient will not be enrolled in the study.
Patient has completed a written informed consent form:
Indicate if the patient signed the 1704 informed consent form. If “No” is indicated and the form is processed, the patient will not be enrolled in the study.
Exclusion criteria
Patient has undergone prior allogeneic hematopoietic transplantation:
Indicate if the patient has ever received an allogeneic HCT (e.g. related or unrelated). If “Yes” is indicated and form is processed, the patient will not be enrolled in the study.
System-generated answers (NO RESPONSE REQUIRED)
Is the patient eligible based on the inclusion/exclusion criteria responses?
If the patient meets all inclusion and exclusion criteria, this system-generated determination will reflect “Yes,” and the subject status will be updated to “Enrolled.” If the patient does not meet all inclusion and exclusion criteria, this system-generated determination will reflect “No,” and the subject status will be updated to “Screen Failed.”
Enrollment date:
This system-generated date will reflect the date when the informed consent form was signed.
CCG v.4.0 | CRF v.3.0
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