2150: Viral Infection Diagnosis and Treatment Form

The CMV / EBV / ADV / HHV-6 / BK Viral Infection Diagnostic Form captures information regarding the diagnosis, treatment, and status of the following infections:

• Cytomegalovirus (CMV)
• Epstein-Barr Virus (EBV)
• Adenovirus (ADV)
• Human Herpes Virus 6 (HHV-6)
• BK Virus (BK)
  

A Viral Infection Diagnostic Form will come due any time one of the above viral infections is reported on the Post-HCT Follow-Up Data Form (2100). For CMV and HHV-6, this form will come due only if there is at least one infection site other than “Blood.” One form must be completed for each applicable infection reported. The reporting period for this form corresponds to the Post-HCT Follow-Up Data Form on which the infection was reported.

See the Post-HCT Follow-Up Data section of the manual for more information on reporting infections.

Links to Sections of Form
Q1-31: Infection Episode
Q32-50: Hematologic Findings at Diagnosis of Infection
Q51-76: Therapy
Q77: Infection Status at the Time of Evaluation for this Reporting Period

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
6/25/18	2150: Viral Infections	Modify	Added (in red below) and removed (struck out below) text from the instructions for reporting infection status at the time of evaluation for this reporting period (question 77): If the status of the infection is not documented in the HCT / cellular therapy physician’s note summarizing their last evaluation performed during the reporting period, obtain documentation from the provider indicating which option to report. For reporting purposes, centers should indicate “Ongoing” if the infection is still present, but cannot be considered improved or resolved. Ongoing: Infection is still present, but cannot be considered improved or resolved Improved: Still on treatment, but responding to treatment and no longer showing signs / symptoms of infection Resolved: Treatment completed Unknown
6/25/18	2150: Viral Infections	Modify	Added (in red below) further instruction on reporting therapy (question 51): Report “Yes” if the recipient received any antiviral medication between seven days prior to the date of diagnosis (refer to question two) and the date of contact for the reporting period (refer to the date of contact reported on the corresponding Post-HCT Follow-Up Data Form). Report all therapy received regardless of the infection being treated.
5/1/18	2150: Viral Infections	Add	Version 1 of the 2150: Viral Infections section of the Forms Instruction Manual released. Version 1 corresponds to revision 1 of the Form 2150.

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