Donor Outcome Form - Report On Donation Procedure And Up To 30 Days After Page 2
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1
2Donor outcome
Long term follow up report after last donation procedure
(To be also used if reporting the death of a donor shortly after donation)
TRANSPLANT CENTRE AND RECIPIENT IDENTIFICATION
FOLLOW UP OR DEATH REPORT
EBMT CIC _________
CENTRE ID CENTRNR
Date of last follow up or death: _____ ____ ___
(if known)
IDAABCCHDB
yyyy
mm
dd
FU Report:
__ month
__ year
EBMT database number _________
IDAA
(if known)
Date of this report: _____ ____ ____
RPRTDATE
Center of HSCT: __________________________
yyyy
mm
dd
Hospital/unit: ____________________________
CENTR
SAE/SAR SINCE LAST REPORT
Unique Patient Number or Code …………….
UPN
M
HEMMALGN
IDAABCCHDBEA
ALIGNANCY
Hematological malignancy?
no
yes
unknown
Initials: _________ ________(first name(s)_surname(s))
If yes: ICD 10 Code: ___.__
GIVNAME FAMNAME
(see manual, list in Appendix l)
Date of birth:
_____ ____ ____
DATPATBD
Confirmed by medical data
no
yes
unknown
M
yyyy
mm
dd
Date of the SAE/SAR _____ ____ ____
IDAABCCHBDDE
yyyy
mm
dd
Date of HSCT:
_____ ____ ____
IDAABC
NHEMALGN
IDAABCCHDBEA
yyyy
mm
dd
Non-hematological malignancy?
no
yes
unknown
COLLECTION CENTRE IDENTIFICATION
if yes: ICD 10 Code: ___.__
(see manual, list in Appendix l)
Confirmed by medical data
no
yes
unknown
M
…………………………... ......
EBMT Code (CIC):
Date of the SAE/SAR _____ ____ ____
(If known)
IDAABCCHBDDE
yyyy
mm
dd
Collection center: …………………………..............
N
AUTOIMMN
IDAABCCHDBEA
ON MALIGNANCY
Autoimmune disease?
no
yes
unknown
Registry: …………………………..............................
if yes: ICD 10 Code: ___.__
(see manual, list in Appendix l)
………………………………………………………......
Confirmed by medical data
no
yes
unknown
M
Date of the SAE/SAR _____ ____ ____
Contact person: ………………………..……………
IDAABCCHBDDE
yyyy
mm
dd
REMINDER please report SAE/SAR to your National authority
PRODUCT
according to your regulations. If donor is unrelated, report also to
BM (Including collection of MSC)
WMDA SEAR registry
STEMCEDO
PBSC
DONOR STATUS ON THIS DATE
Alive
DONSTAT
Both (BM and PBSC)
Unstimulated leukapheresis
Dead: Donation related
no
yes
unknown
(e.g. donor lymphocytes (DLI), etc.)
other, specify __________________________
ICD 10 code for main cause of death: ___.__
(
Select only one main cause)
ICD 10 code(s) for contributory causes of death:
___.__
___.__
___.__
DONOR DATA
Donor number/ID: ……..
………………………………
(See manual: list of ICD 10 codes in Appendix l)
………………………………………………………………
Describe below the cause of death if necessary:
……………………………………………………………
Initials:
__
__
(first name(s)_surname(s))
Check here if donor lost to follow up
_____ ____ ____
Date of birth:
yyyy
mm
dd
DONOR BEHAVIOUR
Sex:
male
female
Would the donor donate again?
DONBEHAV
no
yes
unknown
COMMTDNR
If no: reason: ______________________________
EBMT Donor outcome form Donation procedure report December 2012
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