FORMAL REQUEST CORD

PATIENT DATA

Patient Name:	Date of birth: (DD/MM/YYYY)
Patient ID: (assigned by patient’s registry)	Patient ID: (assigned by donor’s registry)	Patient Registry:
Sex:	CMV:	Blood Group:	Weight: kg
Diagnosis:	Current disease status:
DNA Typing: please attach lab report (if not available, please enter HLA below) Typing date:
A	B	C	DRB1	DRB 3/4/5	DQB1
A	B	C	DRB1	DRB 3/4/5	DQB1

CORD BLOOD DATA

CBU ID: Local CBU ID, if available: CBU Registry/Pool:
Date of birth: (DD/MM/YYYY)	Sex:	CMV:	Blood Group:
DNA Typing: please attach lab report (if not available, please enter HLA below) Typing date:
A	B	C	DRB1	DRB 3/4/5	DQB1
A	B	C	DRB1	DRB 3/4/5	DQB1

DNA SPECIMEN REQUEST

CBU confirmatory typing should be performed by:	TC CBB
If confirmatory typing by TC: Shipping address: ,	Contact Name:
Phone:
DNA sample shipment date:

CBU SHIPMENT REQUEST

Delivery address of the CBU: ,	Contact Name:
Phone:
Preferred shipment days (3 dates required) of Transplant Center:
1.	2.	3.

CBU Standard Testing

Control/Verification Typing result	Must be available before CBU Shipment
Viability result	Must be available before CBU shipment
Hemoglobinopathy results (take approx. 7 days) must/can be available:	Before CBU shipment	After CBU Shipment
Potency result (takes approx. 14 days) must/can be available	Before CBU Shipment	After CBU Shipment

FORMAL REQUEST CORD

Patient Name:	Patient Registry:
Patient ID: (assigned by patient’s registry)	Patient ID: (assigned by donor’s registry)

Transplant information and history

Patient Preparation: days, starts on	Transplantation: Intended for
Unit pooled with other CBU’s:	Yes No
Has this patient received any previous stem cell tansplants? Yes No If YES, specify source of stem cells AND specify reason for subsequent transplant: Autologous Related Donor Allogeneic Donor Cord Blood Reason for subsequent transplant:

Unit Transport

Unaccompanied CBU Transport will be organised by:	CBU Registry/CBB Patient Registry/TC

BY REQUESTING THIS CORD BLOOD UNIT (CBU) FOR THE PURPOSE OF TRANSPLANTATION ON BEHALF
OF THE ABOVE NAMED PATIENT, I CONFIRM THAT:

The document POL_002_regulatory_cord gives an overview on the conditions for requests regarding Swiss Cord Blood Units from Swiss Blood stem cells (SBSC).

I have reviewed all available data and laboratory test results of this CBU and will take full responsibility for the results of infusing this CBU to my patient.

The CBU mentioned above is intended solely for the purpose of immediate therapeutic treatment for the above mentioned patient. No other uses of these cells are permissible.
If for any reason, this CBU is not used for the purpose of transplantation for this patient, the Transplant Center will not return this unit to the Cord Blood Bank. Instead, the Transplant Center will take care to dispose of properly. SBSC must be provided detailed information concerning the use or disposal of CBU.

The Transplant Center agrees to provide SBSC post transplant data by completing forms supplied.

It is the responsibility of Cord Blood Bank to choose the method of CBU transport.

The Cord Blood Bank and its affiliates are freed of responsibility for the safe arrival of the CBU once it is handed to the courier.

The CBU must arrive at TC before patient conditioning.

The Transplant Center resumes full responsibility for the return of the dry shipper (in case the dry shipper is provided by the Cord Blood Bank) within 1 week of arrival at the Transplant Center. In case of failure to do so or in case of damage or loss, the transplant center will reimburse the Cord Blood Bank for the cost of the dry shipper, based on current market value of a new dry shipper.

Concerning Swiss Cord Blood Units, after signing this form the transplant center owes the full amount for procurement and all other incoming expenses to SBSC.

TRANSPLANT PHYSICIAN COMPLETING FORM

Signature:	Date: (DD/MM/YYYY)