Add additional log lines if reporting more than one Mixed Chimerism for this reporting period
Date blood drawn __________
Enter the date of blood draw. Enter the date in the DD/MMM/YYYY format.
Whole blood _______ %
Indicate the percentage of whole blood that is associated with the recipient.
CD3+ cells _______ %
Indicate the percentage of CD3+ cells that are associated with the recipient.
CD3+ cells not tested ☐
If CD3+ cells was not performed, leave empty and check this box.
CD15+ cells _______ %
Indicate the percentage of CD15+ cells that are associated with the recipient.
CD15+ cells not tested ☐
If CD15+ cells was not performed, leave empty and check this box.
CD19+ cells _______ %
Indicate the percentage of CD19+ cells that are associated with the recipient.
CD19+ cells not tested ☐
If CD19+ cells was not performed, leave empty and check this box.
CD34+ cells _______ %
Indicate the percentage of CD34+ cells that are associated with the recipient.
CD34+ cells not tested ☐
If CD34+ cells was not performed, leave empty and check this box.
CCG v.1 | CRF v.1
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