Infusion date __________
Enter the infusion date in the DD/MMM/YYYY format.
Recipient weight at infusion _______ kg
Enter the participants weight at infusion in the “NNN.NN” format. This format allows for three digits before the decimal and up to two digits after.
Thawed Product Infusion
DIN/UPI __________
Enter the DIN/UPI associated with the thawed Treg product.
Treg count _______ x 10 6
Volume _______ mL
Enter the CD34 infusion start and completion time (24-hour format)
Was the product fully infused?
Indicate if the Treg product was fully infused. If “No” is selected, enter the volume infused and the Treg count in the “NNNNNNNNNN” format. This allows for ten digits without a decimal.
Were any adverse events reported during product infusions or post-infusion observation? If Yes, complete and submit an Adverse Event report regarding the infusion of the cellular products and submit within 24 hours of the event.
- Yes
- No
CCG v.1 | CRF v.1
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