Q1-13: Demographics

*This form must be completed for all individuals on whom data is submitted to CIBMTR. CIBMTR is a Public Health Authority (PHA) under the Health Insurance Portability and Accountability Act (HIPAA). In this capacity, CIBMTR is authorized to collect individually identifiable health information without consent or authorization of the individual. The PHA designation also allows transplant centers, which fit the definition of covered entities, to disclose these data to CIBMTR under 45 CFR 164.512 (Privacy Rule) without direct consent or authorization of the recipient.

Complete all data fields as thoroughly as possible.

Questions 1-2: First Name, Last Name

Report the individual’s complete legal first name in question 1 and complete legal last name in question 2. If you are unable to report the full legal name, reporting initials or partial name can reduce duplicate CRIDs.

Question 3: Date of birth

Reporting the individual’s date of birth is required for all Form 2804 submissions. Report the individual’s date of birth and continue with question 4.

Questions 4-6: Location of birth

Report the individual’s country of birth in question 4. If applicable, specify city and state of birth in questions 5-6, respectively.

Question 7: Sex

Reporting the individual’s sex is required for all Form 2804 submissions. Report the individual’s biological sex and continue with question 8.

Question 8: Ethnicity

Indicate the recipient’s ethnicity. The United States Office of Management and Budget (OMB) has defined ethnicity as culturally or geographically determined. The distinction between Hispanic and non-Hispanic is for the purpose of the United States census and reporting of SCTOD data. According to OMB, “Hispanic” is an ethnic designation based upon where someone (his or her ancestors) was raised (e.g., “Latin America”). Hispanic people may be of any race. CIBMTR recognizes regional differences with regard to the interpretation of ethnicity throughout the world.

If the recipient is not a resident of the USA, select “not applicable.”

If the recipient declines to provide this information or the recipient’s ethnicity is not documented, select “unknown.”

For more information regarding ethnicity, see Appendix I .

Question 9: Race (check all that apply)

Indicate the recipient’s race. If this recipient has reported that they are more than one race, check each race indicated in the list below that applies. The race groups provided are specific to the United States.

For non-U.S. centers, select “not reported” if the rules / regulations of your country prohibit the collection or reporting of race data (or due to lack of documentation). If race is reported, it may be necessary to consult with the recipient to select the race group(s) with which they most closely identify.

If the recipient declines to provide this information, select “not reported.”

If the recipient’s race is not documented, select “unknown.”

For more information regarding race, see Appendix I .

Question 10: Race detail (check all that apply)

Indicate the detailed race of the recipient. If this recipient has reported that they are more than one detailed race, check each detailed race indicated in the list below that applies.

If the race detail is not documented or is not known, select “unknown.”

For more information regarding race, see Appendix I .

Question 11: Social security number

Report the individual’s social security number. If the individual’s social security number is unknown or the individual is not a United States citizen, leave this data field blank.

Question 12: Cadastro de Pessoas Físicas (CPF) (Brazilian citizens only)

If the individual is a citizen of Brazil, report their 11-digit Cadastro de Pessoas Físicas (CPF). If the individual’s CPF is unknown or the individual is not a Brazilian citizen, leave this data field blank.

Question 13: Patient’s mother’s maiden name (optional for non-U.S. centers)

Report the individual’s mother’s maiden name. This field may be left blank if the individual’s mother’s maiden name is unknown, the HCT recipient declined to release mother’s maiden name, or your transplant center is located outside the United States.

Section Updates:

Question Number	Date of Change	Add/Remove/Modify	Description	Reasoning (If applicable)
Q9	3/9/2021	Remove	The following instructions were removed: _Indicate the recipient’s race. If this recipient has reported that they are more than one race, check each race indicated in the list below that applies. The race groups provided are specific to the United States. If the recipient is White, Southeast Asian, or Pacific Islander, but a more specific Race Detail is not available, report the patient is “Other [White, Southeast Asian, or Pacific Islander respectively].	Removed incorrect instructions
Q10	3/9/2021	Add	The following instructions were added: Indicate the detailed race of the recipient. If this recipient has reported that they are more than one detailed race, check each detailed race indicated in the list below that applies. If the race detail is not documented or is not known, select “unknown.”	Added for clarification

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