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.
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 |
| Form 2003 | Gene Therapy Product | $25* | CIBMTR |
| * Form 2006 and 2003 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 2149 | Respiratory Virus Post-Infusion Form | $20* | CIBMTR |
| Form 2900 | Recipient Death Data | $15 | CIBMTR |
| * Effective January 1, 2023 | |||
| Gene Therapy Infusions | |||
| Form 2000+ | Recipient Baseline Form, plus disease specific inserts | $135 | CIBMTR |
| Form 2003+ | Gene Therapy Product Form | ||
| + These two 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 2149 | Respiratory Virus Post-Infusion Form | $20* | CIBMTR |
| Form 2900 | Recipient Death Data | $15 | CIBMTR |
| * Effective January 1, 2023 | |||
| Cellular Therapy Essential Data (CTED) Forms | |||
| Form 4000* | Pre-Cellular Therapy Essential Data Form | $150 | CIBMTR |
| Form 4003* | Cellular Therapy Product Form | ||
| Form 4006* | Cellular Therapy Infusion Form | ||
| Form 2402* | Disease Classification Form | ||
| * These four forms will be paid as a unit when all required forms are received. Not all cellular therapies require a F2402 or F2005. | |||
| Form 4003+ | Cellular Therapy Product Form | $10 | CIBMTR |
| Form 4006 R1/2+ | Cellular Therapy Infusion Form | $25 | CIBMTR |
| Form 4006 R3+ | Cellular Therapy Infusion Form | $15 | CIBMTR |
| +Paid separately when associated with a Pre-TED F2400. | |||
| Form 4100 | Post Cellular Therapy Essential Data Form | $120 | CIBMTR |
| Form 2011 / 2013 / 2016 / 2018 | Disease-Specific Pre-Treatment Insert for ALL, CLL. PCD or LYM | $80 | CIBMTR |
| Form 2111 / 2113 / 2116 / 2118 | Disease-Specific Post Disease Insert for ALL, CLL, PCD or LYM | $80 | CIBMTR |
| Form 3500 | Subsequent Neoplasms | $25 | CIBMTR |
| Form 3501 | Pregnancy | $25 | CIBMTR |
| Form 2900 | Recipient Death Data | $15 | 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, effective January 20, 2020, Study Forms will be paid only if completed within one calendar year of the form due date. Forms are paid at the following rate:
| 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 | ||
| Supplemental Data Form | $200 / form | ||
| SC17-03: Use of Tepadina as part of prep regimen followed by HCT |
Form 2540 | Tepadina Supplemental Data Form | $100 / form |
| SC17-10: PASS study of Inotuzumab to characterize post-HCT for B-Cell ALL |
Form 2541 | Inotuzumab Supplemental Data Form | $100 / form |
| SC18-10: ALL patients who receive blinatumomab vs. chemotherapy |
Form 2011 and 2111 (TED track only) | No supplemental data form | $110 / form |
| SC18-09: Safety of Allo transplant patients who received mogamulizumab |
Form 2542 | Mogamulizumab Supplemental Data Collection Form | $1000 for 1st patient enrolled and then $500 / form |
| SC19-12: Safety of gemtuzumab treatment for adult AML patients |
Form 2543 | Mylotarg Supplemental Data Collection Form | $700 / form |
Last modified:
Mar 02, 2023