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Q1 – 29: Recipient Information

Question 1: Date of birth

The date of birth is automatically populated based on the value reported in the CRID Assignment tool in FormsNet3SM. Verify that the date of birth is correct. If an error is noted, correct the CRID Assignment tool and verify that the date of birth has been updated on the Pre-TED (2400) Form.

Question 2: Sex

The recipient’s sex is automatically populated based on the value reported in the CRID Assignment tool in FormsNet3SM. Verify that the recipient’s sex is correct. If an error is noted, correct the CRID Assignment tool and verify that the recipient’s sex has been updated on the Pre-TED (2400) Form.

Question 3: Geographic ancestry (select one or more options that closest identifies the recipient’s background)

This data field is disabled as geographic ancestry is reported on the Race, Ethnicity and Ancestry (REA) (2807).

Question 4: Geographic ancestry detail (select one or more options that closest identifies the recipient’s background)

This data field is disabled as geographic ancestry detail is reported on the Race, Ethnicity and Ancestry (REA) (2807).

Question 5: Country of primary residence

Select the recipient’s primary country of residence.

Question 6: State of residence of recipient (for residents of Brazil)

If Brazil was selected as the recipient’s primary country of residence, enter the recipient’s state of permanent residence.

Question 7: Providence or territory of residence of recipient (for residents of Canada)

If Canada was selected as the recipient’s primary country of residence, enter the recipient’s providence or territory of permanent residence.

Question 8: State / territory of residence of recipient (for residents of USA)

If the United States was selected as the recipient’s primary country of residence, enter the recipient’s state of permanent residence.

Question 9: Is the recipient stationed on an overseas US military base?

Indicate if the recipient was stationed on an overseas US military base at the start of the preparative regimen (or infusion if no preparative regimen was given).

Question 10. NMDP Recipient ID (RID)

The NMDP RID is automatically populated based on the value reported on the CRID Assignment (2804) Form. Verify that the NMDP RID is correct. If an error is noted, correct the CRID Assignment (2804) Form and verify that the NMDP RID has been updated on the Pre-TED (2400) Form.

Question 11: ZIP or postal code for place of recipient’s residence (USA and Canada recipients only)

Enter the ZIP code in which the recipient resides. For USA residents, only five digits are required in the format of 12345; however, if the ZIP+4 (nine digit) code is available, report the nine-digit code as 12345-6789. For Canadian residents, report the six-digit code, which consists of both letters and numbers in the format of A1A 1A1.

The postal code is optional for Canadian residents. The question can be answered or left blank without error for Canadian residents.

Question 12: Does the recipient require interpreter services? (any interpreter for any level of care ex. reading / verbal)

The intent of this question is to determine care access, regardless of the language spoken. Indicate if the recipient (or their parent, guardian, or legally authorized representative) requires interpreter services for any aspect of care, including verbal communication, reading, or other forms of assistance. Interpreters may include professional interpreters, family members, friends, or other individual who help facilitate communication.

Question 13: Is the recipient an emancipated minor?

An emancipated minor is a person under the age of 18 who has been legally granted the rights and responsibilities of an adult. Indicate if the recipient was an emancipated minor at the start of the preparative regimen (or infusion if no preparative regimen was given).

Question 14: Specify the recipient’s current relationship status

Report the recipient’s relationship status at the start of the preparative regimen (or infusion if no preparative regimen was given).

  • Single, never married: If the recipient has never been married and is not currently living with a partner.
  • Married or living with a partner: If the recipient is currently married or living with a partner, regardless of whether the partnership is legally formalized.
  • Separated / Divorced: If the recipient was married in the past but is now separated (legal separation is not required) or divorced.
  • Widowed: If the recipient’s spouse passed away and is no longer married.

Question 15: What is the highest degree or level of school that the recipient has completed?

Select the option that best describes the recipient’s highest degree obtained / highest level of school completed at the start of the preparative regimen (or infusion if no preparative regimen was given).

Question 16: Is the recipient covered by health insurance?

Indicate if the recipient is covered by any type of health insurance at the start of the preparative regimen (or infusion if no preparative regimen was given).

Question 17 – 21: Specify type of health insurance (check all that apply)

Select the recipient’s health insurance coverage at the start of the preparative regimen (or infusion if no preparative regimen was given). Select all that apply.

  • Private health insurance: Health insurance purchased by the recipient or recipient’s family, through an employer / union or an insurance company. Private health insurance includes ACA / Obamacare. If selected, specify the type of private insurance.
  • National Health Insurance (Government-sponsored, non-U.S.): A government-sponsored, non-U.S. health insurance system covering the cost of healthcare for a country’s population. Examples include UK’s National Health Service and Australia’s Medicare system.
  • Medicare (Government-sponsored, U.S., includes Medicare Advantage plans): A government-sponsored, U.S. health insurance program for anyone > 65 years, some people < 65 years old with certain conditions / disabilities, and those with end stage renal disease. If selected, specify the type of Medicare.
  • Medigap (Must have Medicare coverage): Also known as Medicare Supplement Insurance. If already covered by Medicare, additional health insurance may be purchased from a private insurance company to cover additional out-of-pocket costs.
  • Medicaid (Government-sponsored, U.S.): A government-sponsored, U.S. health insurance program providing coverage for those with limited income.
  • Children’s Health Insurance Program (CHIP): Health insurance coverage provided for children whose family does not qualify for Medicaid.
  • Military-related health care (TRICARE (CHAMPUS) / VA health care / CHAMP-VA): Military-related health care provided by the Department of Defense or the Department of Veterans Affairs.
  • Indian Health Service: A federal agency within the Department of Health and Human Services providing health care to American Indians and Alaska Natives.
  • State-sponsored health plan: Health insurance program funded by both state and federal governments. Currently, there are three such programs: MinnesotaCare, Basic Health Program (NY), and Oregon Health Plan Bridge Program.
  • Disability insurance: A type of insurance that replaces a portion of lost income for those who are unable to work due to illness or injury. Disability insurance may be available through an employer, the government, or private insurance.
  • Other government program: If the recipient’s health insurance coverage is a government-sponsored but not listed above, specify the type of government program health insurance.
  • Other health insurance coverage: If the recipient’s health insurance coverage is not government-sponsored and not listed above, specify the type of coverage.

Question 22: Is the recipient participating in a clinical trial?

For the infusion being reported on this form, indicate if the recipient is a registered participant of a clinical trial regardless of if that sponsor uses CIBMTR forms to capture outcomes data. Only clinical trials relating to the infusion intervention and are known and consented at the time of infusion should be reported. This includes trials related to, but not limited to, the graft source, GVHD prophylaxis, or the preparative regimen. Report any clinical trial, including upfront or relapse chemotherapy, only if the sponsor is COG or if the recipient is enrolled on the PedAL study, COG APAL2020SC.

If the recipient is not participating in a clinical trial or it is unknown, select No.

Submit a ticket through CIBMTR Center Support when there are questions on reporting clinical trials.

Questions 23 – 28: Sponsor

Select the study sponsor of the clinical trial the recipient is participating in from the list below.

Question 29: Specify the ClinicalTrials.gov identification number

All clinical trials are required to be registered on the clinicaltrials.gov website and will have an associated identification number.

Report the identification number. Do not include the letters “NCT,” preceding the digits.

Section Updates:

Question Number Date of Change Add/Remove/Modify Description Reasoning (If applicable)
Q12 1/23/2026 Add Clarified question intent: The intent of this question is to determine care access, regardless of the language spoken. Indicate if the recipient (or their parent, guardian, or legally authorized representative) requires interpreter services for any aspect of care, including verbal communication, reading, or other forms of assistance. Interpreters may include professional interpreters, family members, friends, or other individual who help facilitate communication. Added for clarification
Last modified: Jan 26, 2026

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