FORMAL WORKUP	REQUEST FOR STEM CELL COLLECTION

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:
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

DONOR DATA

GRID/Related ID: Donor’s Registry/Pool:
Date of birth: (DD/MM/YYYY)	Sex:	CMV:	Blood Group:	Weight: kg
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

TRANSPLANT CENTER

Address: ,	Contact Name: Phone: Phone 24h/7d:

PRODUCT REQUEST

Product preference Bone Marrow (BM) Peripheral Blood Stem Cells (PBSC) Please fill in a numeric value next to both products to indicate preference: 1 = 1st preference.; 2 = 2nd preference; 0 = not desired if 1st preference not possible If PBSC only, please indicate if you require emergency BM in case of poor mobilization: Yes, please provide BM prescription No
Preferred collection dates (DD/MM/YYYY) List your preference for the first collection day, note that a PBSC request may require a two-day collection
1.	2.	3.
Request for First Day Pickup: Yes
Minimum number of days prior to collection that the donor clearance must be received:
Number of days of conditioning prior to transplant: (Conditioning of patient must not be started until the registry has confirmed the donor to be medically fit and the results of all screen tests are known and have been reported to and accepted by the Transplant Center.)
Are any other donors still under consideration for donation on behalf of this patient?	Yes No
Are any other donors in work-up on behalf of this patient?	Yes No
If you have answered yes to either of these questions, is the donor requested for stem cell collection on this form the preferred donor?	Yes No

FORMAL WORKUP REQUEST FOR STEM CELL COLLECTION

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:

DONOR DATA

GRID/Related ID:	Donor’s Registry/Pool:

PATIENT STATUS REPORT

Diagnosis: Current Disease Status/No. of remissions (if applicable): Karnofsky/Lansky Score: Brief description of clinical condition: Conditioning regimen: Myeloablative Reduced/Minimal Sequential Are there any specific procedures (i.e. splenectomy) that your patient will have done prior to transplant? This workup is considered: Standard: Urgent: Reason for urgent request: Medical history: Has this patient received any previous stem cell transplants? Yes / How many ______ No If yes, specify source of stem cells: Autologous Related Allogeneic Donor Unrelated allogeneic Donor Cord Blood

REQUIRED DOCUMENTATION TO ACCOMPANY THIS REQUEST

Copy of patient and donor laboratory HLA typing results

Transplant Physician:	Signature:	Date: (DD/MM/YYYY)

PRESCRIPTION FOR PERIPHERAL BLOOD STEM CELL

(PBSC) COLLECTION

To be completed by the Transplant Center

PATIENT DATA

Patient Name:	Patient ID: (assigned by patient’s registry)
Transplant center: , ,	Patient ID: (assigned by donor’s registry)

DONOR DATA

GRID/Related ID: Donor’s Registry/Pool:

PRE-COLLECTION PERIPH. BLOOD SAMPLES (max. 50 ml) Samples needed: Yes	No

ml EDTA	ml ACD	Other, please specify:
ml Heparin	ml no anticoagulant
Samples to be shipped to: ,	Contact Name: Phone no: NOTE: This blood will be shipped at the time of the donor physical exam unless otherwise requested. Prefered date of shipment: Monday - Thursday

STIMULATED PBSC COLLECTION

Required CD34+ cells / kg	x 10^6/kg
x recipient weight (kg)	kg
= total number of CD34+ cells	x 10^6
+ CD34+ cells for quality testing	x 10^6
= total number of CD34+ cells	x 10^6
Reason for a request if more than 5 x 10^6/kg:
Preferred method of overnight storage (if needed) of apheresed product: 2° - 8°C other (indicate)	Donor Plasma Requirements: Yes No If yes, quantity: ml in a separate bag added to the final product
Transport Temperature: 2° - 8°C other (indicate)
Additional comments:

PERIPHERAL BLOOD SAMPLES TO BE COLLECTED AT TIME OF FIRST APHERESIS (max. 50 ml)

ml EDTA	ml ACD	ml Product Sample
ml Heparin	ml no anticoagulant	Other:
Additional comments:

DISCLAIMER: The cell products collected from this donor are intended solely for the purpose of immediate therapeutic treatment for the above mentioned patient. Excess cells may be stored for future infusion for this patient. No other uses of these cells are permissible. Cells not used for the therapeutic treatment of the above mentioned patient must be disposed of properly. The donor center must be provided detailed information concerning the use and/or disposal of all portions of this cell product. By accepting these cells, the transplant physician also accepts these terms and conditions. Requests for deviations from these terms must be submitted before donations in writing to the donor center for approval.

Transplant Physician:	Signature:	Date: (DD/MM/YYYY)

PRESCRIPTION FOR MARROW COLLECTION

To be completed by the Transplant Center

PATIENT DATA

Patient Name:	Patient ID: (assigned by patient/donor registry)
Transplant center: , ,	Patient ID: (assigned by donor’s registry)

DONOR DATA

GRID/Related ID: Donor’s Registry/Pool:

PRE-COLLECTION PERIPH. BLOOD SAMPLES (max. 50 mls) / Samples needed: Yes	No

ml EDTA	ml ACD	Other, please specify:
ml Heparin	ml no anticoagulant
Samples to be shipped to: ,	Contact Name: Phone no: NOTE: This blood will be shipped at the time of the donor physical exam unless otherwise requested. Prefered date of shipment: Monday - Thursday

MARROW COLLECTION

Required Nucleated Cells/kg (uncorrected)	x 10^8/kg
x recipient weight (kg)	kg
= Total Nucleated Cells for recipient (uncorrected)	x 10^8
+ Nucleated Cells for quality assurance	x 10^8
= Total Nucleated Cells	x 10^8
Reason for request if more than 4 x 10^8/kg
Transport Temperature: 2° - 8°C other (indicate)

PERIPHERAL BLOOD SAMPLES TO BE COLLECTED AT TIME OF COLLECTION (maximum 50 ml)

ml EDTA	ml ACD	mls Product Sample
ml Heparin	ml no anticoagulant	Other:
Additional comments:

DISCLAIMER: The cell products collected from this donor are intended solely for the purpose of immediate therapeutic treatment for the above mentioned patient. Excess cells may be stored for future infusion for this patient. No other uses of these cells are permissible. Cells not used for the therapeutic treatment of the above mentioned patient must be disposed of properly. The donor center must be provided detailed information concerning the use and/or disposal of all portions of this cell product. By accepting these cells, the transplant physician also accepts these terms and conditions. Requests for deviations from these terms must be submitted before donations in writing to the donor center for approval.

Transplant Physician:	Signature:	Date: (DD/MM/YYYY)