This form must be completed for all infusions for recipients of non-HCT cellular therapy (including post-HCT “DCI / DLI” infusions). For recipients of hematopoietic cellular transplants (HCT), complete the Hematopoietic Stem Cell Transplant (HCT) Infusion (2006) form.

The Cellular Therapy Infusion (4006) form is designed to capture infusion-specific information for all infusions given to a recipient as part of a course of cellular therapy. In addition to use in research, this information is used for quality assurance measures, both by the NMDP and the Cord Blood Banks.

Product specific information is collected on Cellular Therapy Product (4003) form. A Cellular Therapy Product (4003) form is required for each product and a Cellular Therapy Infusion (4006) form is required for each infusion of that product. For example, a single product may be infused three times per course of cellular therapy. In this scenario, one Cellular Therapy Product (4003) form and three Cellular Therapy Infusion (4006) forms would be completed.

If more than one infusion occurs, as defined by event date, each infusion must be analyzed and reported on a separate Cellular Therapy Product (4006) form. This is true even if the same product is being infused on a later date.

For more information see Appendix D–How to Distinguish Infusion Types and Appendix E–Definition of a Product.

Links to sections of form:
Q1-31: Product Infusion
Q32-35: Concomitant Therapy

Date Manual Section Add/Remove/Modify Description
1/28/2022 4006: Cellular Therapy Infusion Modify Version 6 of the 4006: Cellular Therapy Infusion section of the Forms Instruction Manual released. Version 6 corresponds to revision 6 of the Form 4006.
5/10/2022 4006: Cellular Therapy Infusion Modify Removed Breyanzi from the blue note box below question 14: If the cellular therapy product infused is the commercially available product Kymriah® , BreyanziTM, or Abemca®, this question will be disabled.
Last modified: May 10, 2022

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