<p> FORMAL REQUEST FOR BLOOD STEM CELL COLLECTION RELATED DONORS (FIRST TRANSPLANTS ONLY) RECIPIENT DATA Recipient Name: Recipient ID: (assigned by recipient’s TC/registry) Recipient ID: Recipient ID: (assigned by Anthony Nolan) (assigned by donor’s registry) Diagnosis: Current disease status: </p><p>Gender: ABO Rh: CMV: Weight (kg): Date of Birth: (day/month/year) TRANSPLANT CENTRE Centre Name: Invoice to: Contact Name: Contact Name: Address: Address: </p><p>Phone no: Phone no: Fax no: Fax no: Email: Email: ALL COMMUNICATIONS TO BE VIA ANTHONY NOLAN EXCEPT IN EMERGENCY – ANTHONY NOLAN’S 24 HOUR ON CALL NUMBER IS +44 7710 599 161 DONOR DATA Donor Name: Gender: Weight (kg): CMV: Blood Group: </p><p>Donor ID: Donor location: Date of Birth: (if known) (day/month/year)</p><p>PRODUCT REQUEST Product Preference: _____Bone Marrow (BM) _____ Stimulated PBSC Please fill in a numeric value next to both products to indicate preference: 1=1st preference; 2=2nd preference; 0=not desired if 1st preference not possible</p><p>Are any other donors still under consideration for donation on behalf of this patient? Yes / No Are any other donors in work up on behalf of this patient? Yes / No If yes to either of the questions above, is the donor requested on this form the preferred donor? Yes / No Is this donor requested to consent to participate in an AN-approved clinical trial? Yes / No If yes, what is the name of the trial? ______PREFERRED DATES (in order of preference) For bone marrow, list preferred harvest date. For PBSC collection, please list your preference for the first day's collection: Collection Date: (day/month/year) Corresponding Infusion Date: (day/month/year) 1 1 2 2 3 3 Minimum number of days prior to collection that donor clearance must be received: ______days Number of days of conditioning prior to transplant: ______days Date clearance is needed for 1st choice dates: ______(Conditioning of patient must not be undertaken until the registry has confirmed the donor to be medically fit and the results of all screening tests are known and have been reported to, and accepted by, the Transplant Centre). REQUIRED DOCUMENTATION TO ACCOMPANY THIS REQUEST 1. Copy of all laboratory reports listing HLA typing results of patient and donor. 2. Summary of transplant protocol to be used with the most recent protocol review date. 3. Related Donor Sample Request for HLA Typing 4. Completed Marrow and/or PBSC Prescription form(s). Person Completing Form: Signature: Date: (day/month/year)</p><p>DOC3983 Page 1 of 1 Version 001 (01/17) </p>