The Thalassemia Pre-Infusion (2058) Form is one of the Comprehensive Report Forms. This form captures thalassemia-specific pre-infusion data such as the recipient’s thalassemia diagnosis, donor related information, transfusion, hepatic, cardiac, renal, iron overload assessment prior to the start of the preparative regimen, hematologic labs, organ impairment, and pre-infusion therapy.
This form must be completed for all transplant and gene therapy recipients, randomized to the Comprehensive Report Form (CRF) track whose primary disease is reported as Hemoglobinopathies – Transfusion dependent thalassemia: Transfusion beta dependent thalassemia or Other transfusion dependent thalassemia on the Disease Classification (2402) Form.
Q1: Subsequent Transplant or Cellular Therapy
Q2 – 26: Thalassemia Diagnosis
Q27 – 52: Donor Related Information
Q53 – 59: Transfusion Therapy
Q60 – 62: Hepatic Assessments
Q63 – 67: Cardiac Assessments
Q68: Renal Assessments
Q69 – 74: Additional Iron Overload Assessments
Q79 – 83: Additional Hematologic Labs
Q84 – 94: Specify Existing Other Organ Impairments
Q95 – 101: Disease Modifying Therapies
Sections of the Forms Instruction Manual are frequently updated. The most recent updates to the manual can be found below. For additional information, select the manual section and review the updated text.
If you need to reference the historical Manual Change History for this form, please reference the retired manual section on the Retired Forms Manuals webpage.
|4/22/2019||2058: Thalassemia Pre-Infusion||Add||Version 1 of the 2058: Thalassemia Pre-Infusion section of the Forms Instructions Manual released. Version 1 corresponds to revision 1 of the Form 2058.|
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