Question 4: Specify the disease / study for which non-cellular therapy was given
Indicate if the individual is participating in the BMT CTN 17-02 study or receiving non-cellular therapy as treatment for MDS, multiple myeloma, myelofibrosis, sickle cell disease, or another disease. If the research participant is enrolled in a study or receiving therapy for a disease that is not captured in any of the above categories, specify in question 5
Question 5: Specify other disease / study
If you have indicated in question 4 ‘other disease/study’ please enter the disease or study patient has or will be given therapy for.
Question 6: Enrollment date (date of consent)
Report the date of consent for enrollment on non-cellular therapy protocol. Continue with the signature section of the form.
The FormsNet3SM application will automatically populate the signature data fields, including name and email address of person completing the form and date upon submission of the form.