Fee Schedule for Forms Completion

The CIBMTR pays transplant centers for all completed Comprehensive Report Forms and Cellular Therapy Forms. Reporting of TED level data is not compensated, with the exception of the Form 2006 when requested for recipients on the TED track. Once a form is designated as “CMP” in the FormsNet application, the transplant center will be paid during the next payout time-point. Effective January 1, 2013, Comprehensive Report Forms will be paid only if completed within one calendar year of the form due date. Forms are paid at the following rate:

Data Transmission Agreement / Master Healthcare Data and Sample Submission Agreement Fee Schedule

Form # Description Payment TIN1
Product Insert
Form 2006 HSCT Infusion $25* CIBMTR
* An infusion form (Form 2006) may be paid when requested by CIBMTR for those recipients not on the CRF track. No center will be paid twice for the same form.
Comprehensive Report Forms
Form 2000+ Recipient Baseline Form, plus disease specific inserts $135 CIBMTR
Form 2004+ Infectious Disease Markers (related donor only)
Form 2005+ Confirmation of HLA Typing (related donor only)
Form 2006+ HSCT Infusion Form
+ These four forms will be paid as a unit when all required forms are received.
Form 2100 100 Days Post-HSCT Data, plus any required inserts $110 CIBMTR
Form 2100 Six Months to Two Years Post-HSCT Data, plus any required inserts $85 CIBMTR
Form 2100 Yearly Follow-Up for Greater than Two Years Post-HSCT Data, plus any required inserts $65 CIBMTR
Form 2900 Recipient Death Data $15 CIBMTR
Cellular Therapy Essential Data (CTED) Forms
Form 4000 Pre-Cellular Therapy Essential Data Form $150 CIBMTR
Form 4003 Cellular Therapy Product Form $25 CIBMTR
Form 4006 Cellular Therapy Infusion Form $25 CIBMTR
Form 4100 Post Cellular Therapy Essential Data Form $120 CIBMTR
Form 2011 / 2013 / 2018 Disease-Specific Pre-Treatment Insert for ALL, CLL or LYM $80 CIBMTR
Form 2111 / 2113 / 2118 Disease-Specific Post Disease Insert for ALL, CLL or LYM $80 CIBMTR
Form 3500 Subsequent Neoplasms $25 CIBMTR
Form 3501 Pregnancy $25 CIBMTR
Repository Forms
N/A Repository Sample Received – Related Donor Transplant $35 TC
N/A Repository Sample Received – Unrelated Donor Transplant $10 TC
Form F00227 Repository Excuse Code – Related Transplant $10 TC
Form F00227 Repository Excuse Code – Unrelated Transplant $5 TC

1 Payment is made to the Tax Identification Number (TIN) for the TC# or CIBMTR# as provided by the Center.

Study Forms

For Centers participating in the studies specified below:

Study Name Form Number Description Fee
SP16-02:
Veno-Occlusive Disease (“VOD”) Data Registry
Form 2553 Veno-Occlusive Disease (VOD) / Sinusoidal Obstruction Syndrome (SOS) Supplemental Data Form $300 / form
SC16-06:
Safety of Allo HCT in classical HL patients treated with Nivolumab
Forms are in RAVE; no form ID One Time Start Up Fee $1000
Supplemental Data Form $200 / form
KFG Study Form 2503 KGF Study Supplement $100 / form
Form 2504 KGF Study Long-Term Follow Up $100 / form
SC15-04:
Plerixafor Prospective Registry Study
Form 2565 Mozobil Supplemental Data Form $500 / form
Center Survey $100
SC17-03:
Use of Tepadina as part of prep regimen followed by HCT
Form 2540 Tepadina Supplemental Data Form $100 / form
SC17-02:
Rate and Characterization of VOD in Patients who received Mylotarg pre-HCT
No form Supplemental Data (collected via an Excel file $150
SC17-10:
PASS study of Inotuzumab to characterize post-HCT for B-Cell ALL
Form 2541 Inotuzumab Supplemental Data Form $100 / form
Last modified: 2018/11/19

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