The Thalassemia Pre-Infusion (2058) Form is one of the Comprehensive Report Forms. This form captures thalassemia-specific pre-infusion data such as the recipient’s thalassemia diagnosis, donor related information, transfusion, hepatic, cardiac, renal, iron overload assessment prior to the start of the preparative regimen, hematologic labs, organ impairment, and pre-infusion therapy.
This form must be completed for all transplant and gene therapy recipients, randomized to the Comprehensive Report Form (CRF) track whose primary disease is reported as Hemoglobinopathies – Transfusion dependent thalassemia: Transfusion beta dependent thalassemia or Other transfusion dependent thalassemia on the Disease Classification (2402) Form.
Links to Sections of Form:
Q1: Subsequent Transplant or Cellular Therapy
Q2 – 26: Thalassemia Diagnosis
Q27 – 52: Donor Related Information
Q53 – 60: Transfusion Therapy
Q61 – 63: Hepatic Assessments
Q64 – 72: Cardiac Assessments
Q73 – 75: Renal Assessments
Q76 – 78: Avascular Assessments
Q79: Other Symptoms
Q80 – 89: Additional Iron Overload Assessments
Q90 – 94: Additional Hematologic Labs}
Q95 – 105: Existing Organ Impairments
Q106 – 112: Disease Modifying Therapies
Q113: Marrow Evaluation
Manual Updates:
Sections of the Forms Instruction Manual are frequently updated. The most recent updates to the manual can be found below. For additional information, select the manual section and review the updated text.
If you need to reference the historical Manual Change History for this form, please reference the retired manual section on the Retired Forms Manuals webpage.
| Date | Manual Section | Add/Remove/Modify | Description |
|---|---|---|---|
| 7/26/2024 | 2058: Thalassemia Pre-Infusion | Add | Version 2 of the 2058: Thalassemia Pre-Infusion section of the Forms Instructions Manual released. Version 2 corresponds to revision 2 of the Form 2058. |
Need more help with this?
Don’t hesitate to contact us here.