Questions 8-9: Specify the disease for which non-cellular therapy was given

Indicate if the individual is participating in the BMT CTN 17 – 02 study or receiving non-cellular therapy as treatment for MDS, multiple myeloma, myelofibrosis, sickle cell disease, or another disease. If the research participant is enrolled in a study or receiving therapy for a disease that is not captured in any of the above categories, specify in question 9.

Question 10: Enrollment date (date of consent)

Report the date of consent for enrollment on non-cellular therapy protocol. Continue with the signature section of the form.

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: May 17, 2019

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