Test Results Hematology

*Timeline requirements for this form are as follows:
Assessment timeframe: Pre-Transplant, Day 1, Day 2, Day 3, Day 4, Week 2, Week 3, Week 4, Week 5, Week 6, Week 7, Week 8, Week 10, Week 12, Month 4, Month 5, Month 6, Month 7, Month 8, Month 9, Month 10, Month 11, Month 12, Month 14, Month 16, Month 18, Month 20, Month 22, Month 24, Month 27, Month 30, Month 33, Month 36, Month 48, Month 60.
Submission timeframe: Submit this form after the designated clinic visit with the recipient’s test results entered as indicated.

Transplant site clinical visit
Indicate if the test result was performed at the transplant site clinic or if it was performed at a lab outside of the transplant clinic.

• Yes
• No, results reported through recipient’s referring physician
  

Date blood drawn __________
Enter the date the blood specimen was draw. Enter the date in the DD/MMM/YYYY format.

Hematology Results

WBC results _______ K/µL
Enter the white blood cell count in K/µL. Enter the amount in “NNNNN” format. This format allows for five digits without a decimal.

WBC result out of range ☐
Check the box if the WBC count was out of range according to the lab performing the test.

WBC not done ☐
Check the box if the WBC count was not performed. Leave the WBC results box unanswered.

ANC results _______ K/µL
Enter the absolute neutrophil count in K/µL. Enter the amount in “NNNNN” format. This format allows for five digits without a decimal.

ANC result out of range ☐
Check the box if the ANC was out of range according to the lab performing the test.

ANC not done ☐
Check the box if the ANC was not performed. Leave the ANC results box unanswered.

ALC results _______ K/µL
Enter the absolute lymphocyte count in K/µL. Enter the amount in “NNNNN” format. This format allows for five digits without a decimal.

ALC result out of range ☐
Check the box if the ALC was out of range according to the lab performing the test.

ALC not done ☐
Check the box if the ALC was not performed. Leave the ANC results box unanswered.

Platelet results _______ K/µL
Enter the platelet count in K/µL. Enter the amount in “NNNNN” format. This format allows for five digits without a decimal.

Platelet result out of range ☐
Check the box if the platelet count was out of range according to the lab performing the test.

Platelet not done ☐
Check the box if the platelet count was not performed. Leave the platelet results box unanswered.

Hemoglobin results _______ g/dL
Enter the hemoglobin in g/dL. Enter the amount in “NNNNN” format. This format allows for five digits without a decimal.

Hemoglobin result out of range ☐
Check the box if the hemoglobin count was out of range according to the lab performing the test.

Hemoglobin not done ☐
Check the box if the hemoglobin count was not performed. Leave the hemoglobin results box unanswered.

CCG v.1 | CRF v.1

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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.