Cord Blood Establishing a National Hematopoietic Stem Cell Bank Program (2005) / Chapter Skim
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Appendix B: Survey
Appendix B: Survey
Pages 149-159
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Contact Information Name of individual filling out this survey Cord Blood Bank Name Title/Position Phone Number Fax Address General Background 1. What type of banking service(s)
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Please provide the following: Number of Individuals Consenting to Collection: ________ Number of Units Collected: ________ Number of Units Banked (after testing and screening for low volume) in Total: ________ Number of Units Available for Transplant completed review)
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In what format is unit information stored? Database System Excel Spreadsheet Access Database Other Database ______________ Data Entry Quality Assurance Program Other Collection and Storage 1.
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(Please check all that apply) On whole blood On red cell depleted or mononuclear cell product On cryopreserved aliquot Other____________________________
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Nurse Trained Official Other ______________________ d. Is consent taken more than once (e.g., a preliminary consent followed by a final consent signed later)
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Please check all screening that is completed prior to storage: Genetic Screening Hemoglobinopathy ABO Group Rh Type Health Questionnaire Other ____________ Infectious Disease Testing Alanine Aminotransferase (ALT)
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_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 10. Please discuss the HLA typing procedure carried out on cord blood samples prior to storage.
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A B DR What other criteria beyond HLA typing are used in matching? If other criteria are used, please describe your algorithms for matching using multiple results.
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what testing is mandatory at the time of unit selection prior to transplant? Repeat HLA Typing Genetic Disease Testing Other ________________________ 6.
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must a transplant center meet before receiving units from your bank? NMDP Approved Site for Unrelated Marrow Donor Transplant FACT Accreditation Other ____________________________________________________________ Exceptions allowed based on: 9.
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Currently Historically NIH NIH Private/Philanthropy Private/Philanthropy State-funding State-funding Support from Public Bank Support from Public Bank Revenue Revenue Other ______________ Other _______________ Thank you for your time and concern in helping the committee gather needed information!
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