The Donor Demographic Information section (questions 144-170) is to be completed for all non-NMDP allogeneic donors / CBUs. If the stem cell product was from an NMDP donor or an autologous donor, continue with the signature lines at the end of the form.

Question 144: Was the donor ever pregnant?

If the donor has ever been pregnant, select “yes” and continue with question 145.

If the donor has never been pregnant, select “no” and continue with question 147.

If there is no documentation regarding whether or not the donor has ever been pregnant, select “unknown” and continue with question 147.

If the product is a cord blood unit or was from a male donor, select “Not Applicable (male donor or cord blood unit)” and continue with question 147.

Questions 145-146: Number of pregnancies

Indicate if the number of pregnancies is known or unknown. If “known,” specify the total number of pregnancies in question 146.

If the total number of pregnancies is not known, select “unknown” and continue with question 147.

Question 147: Donor’s ethnicity:

Indicate the donor’s ethnicity. For more information regarding ethnicity, see Appendix I.

Questions 148-149: Donor’s race and detail: (Mark the group(s) in which the donor is a member. Check all that apply.)

Indicate the race of the donor, marking all that apply. For more information regarding race, see Appendix I.

Question 150: Was the donor a carrier for potentially transferable genetic diseases?

If the donor was a carrier for a potentially transplantable genetic disease, select “yes” and continue with question 152. If the donor was not tested, or if there is no documentation of genetic testing, select “no” and continue with question 154.

Questions 151-152: Specify potentially transferable genetic disease:

Indicate the potentially transplantable genetic disease the donor was a carrier for. If the donor was a carrier for a potentially transplantable disease, but the disease was not listed in question 152, select “other disease” and specify the disease in questions 153.

Question 153: Was the donor / product tested for other transferable genetic or clonal abnormalities?

If the donor and/or product were tested for other transferable genetic or clonal abnormalities, select “yes” and continue with question 155. If this is a related donor and/or the donor/product were not tested, or if there is no documentation of genetic testing, select “no” or “unknown,” respectively, and continue with question 160 for related donors or the signature lines at the end of the form for all other donor types.

Questions 154-158: Specify disease(s) tested:

For each of the genetic or clonal abnormalities listed, indicate whether the disease testing was done. Indicate “yes” or “no” and specify the method of testing in the following question. Do not leave any responses blank. If the donor was tested for a potentially transferable genetic or clonal abnormality, but it was not listed in questions 155-157, select “yes” for “other transferable genetic or clonal abnormality” and specify the abnormality in question 159.

Question 159: Did this donor have a central line placed? (non-NMDP PBSC donors only)

This question only applies to non-NMDP PBSC donors. If the donor had a central line placed during the donation process, select “yes” and continue with question 160. If the donor did not have a central line, select “no” and continue with question 160.

Question 160: Was the donor hospitalized (inpatient) during or after the collection?

Indicate “Yes” if the donor was hospitalized for complications during or after the collection. Indicate “No” if the donor was not hospitalized as an inpatient or if the donor was admitted to an observation unit and discharged in less than 24 hours.

Questions 161-162: Did the donor experience any life-threatening complications during or after the collection?

Examples of life-threatening complications include, but are not limited to the following:

  • Allergic reaction to filgrastim
  • Reaction to anesthesia
  • PBSC donors: Low platelet counts (<30,000)
  • Marrow donors: Injury to bone, nerve, or muscle during collection

Many of these criteria are outlined by the Common Terminology Criteria for Adverse Events (CTCAE) and would be reported as a Grade 4 or higher adverse event. For more information on CTCAE complications that can be reported, see the published criteria at: https://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.

If the donor experienced life-threatening complications during or after the collection, select “yes” and specify the complication(s) in question 162.

If the donor did not experience life-threatening complications during or after the collection, select “no” and continue with question 163.

Questions 163-165: Did the allogeneic donor give one or more autologous transfusion units?

If the allogeneic donor gave one or more autologous transfusion units, select “yes” and specify the date of collection of the first unit and total number of units collected in questions 164-165. If the donor did not give autologous blood transfusion units, select “no” and continue with question 166.

Questions 166-168: Did the donor receive blood transfusions as a result of the collection?

Indicate if the donor received blood transfusions as a result of the collection. If the donor received transfusions of their own blood that had been previously collected and stored, even once, indicate “autologous transfusions” and specify the number of units received in question 167.

If the donor received blood transfusions (excluding autologous blood product), indicate “allogeneic transfusions” and specify the number of units received in question 168.

If the recipient did not receive blood transfusions as a result of the collection, select “no” and continue with question 169.

Questions 169-170: Did the donor die as a result of the collection?

If the donor died as a result of the collection, select “yes” and specify the cause of death in question 170. If the donor did not die as a result of the collection, select “no” and continue with the signature lines.

Signature Lines:
The FormsNet3SM application will automatically populate the signature data fields, including name and email address of person completing the form and date upon submission of the form.

Last modified: Aug 21, 2020

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