Donor Outcome Form - Report On Donation Procedure And Up To 30 Days After
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2Donor outcome
Report on donation procedure and up to 30 days after
DONATION PROCEDURE
TRANSPLANT CENTRE AND RECIPIENT IDENTIFICATION
First day of this collection: _____ ___ ___
IDAABCCHDB
EBMT CIC _________
CENTRE ID CENTRNR
yyyy
mm dd
(if known)
EBMT database number _________
IDAA
COLLECTION DATA
(if known)
…………………………..
EBMT Code (CIC):
COLLCNTR
Center of HSCT: __________________________
(If known)
Collection center: …………………………...........
OTHCOLLC
Hospital/unit: ____________________________
CENTR
Donor registry:
Unique Patient Number or Code …………….
………………………….............………………………………......
UPN
Contact person: …………………………………......
CNTCTPRS
Initials: _________ ________(first name(s)_surname(s))
GIVNAME FAMNAME
Date of this report: _____ ____ ____
RPRTDATE
Date of birth:
_____ ____ ____
DATPATBD
yyyy
mm
dd
yyyy
mm
dd
Start date of donation procedure:
_____ ____ ____
DNRCOLST
Date of HSCT:
_____ ____ ____
IDAABC
yyyy
mm
dd
yyyy
mm
dd
Chronological Number of this donation procedure: _____
If >1: Same recipient
no
yes
PRH
ARCEN
PRODUCT
Centre of previous donation: …………………………
BM (Including collection of MSC)
PRVCOLCN
STEMCEDO
_____ ____ ____
Date of previous donation:
PRVCOLDT
PBSC
yyyy
mm
dd
Both (BM and PBSC)
Was the product collection completed?
no
yes
CBININHB
Unstimulated leukapheresis
Were haematopoietic growth factors used?
no
yes
(e.g. donor lymphocytes (DLI), etc.)
if yes, specify…………………………………..
(eg GCSF)
CBININ
other, specify __________________________
Were cell binding inhibitors used,
no
yes
if yes: specify……………………………….
(eg Plerixafor)
Was erythropoietin used?
no
yes
DONOR DATA
Were other drugs used for mobilization?
no
yes
Donor number/ID…………………………………
DONORID2
OTH
Donor signed Informed consent for data transmission to
COMPLICATIONS
the EBMT Registry
DONCONS
in temporal association with the donation procedure
Compulsory, registrations will not be accepted without
Report every serious adverse event occurring within the interval
this item!
between start of the donation procedure and day 30 after the end of
donation procedure with ICD 10 Coding
Initials: ……… ……… first name(s)_surname(s))
(see list in Appendix l of the manual)
DNRHVSAE
DGFGIVN DGFFAMN
Serious Adverse Events (SAE/SAR):
no
yes
unknown
Relationship to recipient:
DONRL
if yes: ICD 10 Code: ___.__
syngeneic
(identical twin)
Date of the SAE/SAR _____ ____ ____
ATSAE/SARDN
identical sibling/non identical twin
yyyy
mm
dd
IDAABCCHBDDE
ICD 10 Code: ___.__
other family member:
matched
Date of the SAE/SAR _____ ____ ____
unmatched
yyyy
mm
dd
IDAABCCHBDDE
Describe relation ______________________
REMINDER please report SAE/SAR to your National
to the recipient
(aunt, uncle, first cousin, etc.)
authority according to your regulations. If donor is unrelated,
report also to WMDA SEAR registry
unrelated donor
DONOR BEHAVIOUR
Date of birth:
_____ ____ ____
DATDONBD
Would the donor donate again?
yyyy
mm
dd
no
yes
unknown
DONBEHAV
Sex:
male
female
DONSEX
If no: reason: ______________________________
COMMTDNR
EBMT Donor outcome form Donation procedure report December 2012
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