Q1-14: Demographics

*This form must be completed for all individuals whose 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 be reported and help to 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. Sex shall refer to an individual’s immutable biological classification as either male or female. Sex is not a synonym for and does not include the concept of gender identity. Report the individual’s biological sex in question 7.

Question 8: 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 US citizen, leave this data field blank.

Question 9: 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 10: Patient’s mother’s maiden name (optional for non-US 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 US.

Question 11: Recipient NMDP ID

Report the seven-digit recipient ID (RID) assigned by NMDP. If the individual has never been assigned an NMDP RID, leave this data field blank. For RELATED donors, do not report the repository sample ID in this field. For UNRELATED donors, the RID is the sample ID.

!If an NMDP RID is assigned after the initial submission of the CRID Assignment (2804) Form or it was missed at initial entry, please edit the CRID Assignment page to add this data.

Question 12: Recipient IUBMID

Report the six-digit IUBMID previously assigned to the individual. The IUBMID is the individual identifier previously assigned by the International Bone Marrow Transplant Registry (IBMTR), which was the precursor to the current CRID system. If an IUBMID was previously assigned, complete and continue with question 16; if no IUBMID was previously assigned, continue with question 17.

Question 13: Team ID

Report the four-digit team ID; this data field is required if question 15 is answered. The Team ID is a precursor to the current CIBMTR center number (CCN) system, used by the IBMTR. If the individual has a previously assigned IUBMID, there should be an associated Team ID.

Question 14: Institution-specific subject ID

Report the subject identifier used for any center-specific outcomes registration, transplant study protocol(s), or other unique subject identifier used for internal institutional tracking. Do not report the recipient medical record number (MRN). If the individual does not have an institution-specific subject ID, leave this data field blank.

Section Updates:

Question Number	Date of Change	Add/Remove/Modify	Description	Reasoning (If applicable)

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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.