Notification Of Donor Clearance Template Page 2
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1
2NOTIFICATION OF DONOR CLEARANCE
F80
Page 2 of 2
HPC, Marrow
HPC, Apheresis
MNC, Apheresis
PATIENT DATA
Patient name:
Patient registry:
Date of birth: (YYYY-MM-DD)
Patient ID:
Patient ID:
(assigned by patient registry)
(assigned by donor registry)
DONOR DATA
Donor registry:
Donor ID:
ADDITIONAL DONOR INFORMATION
Comments/attachments:
Based on the results of the donor history, examination and test the donor has no medical problems which
would make him/her unsuitable for the donation. The donor is in good health and a fit candidate for bone
marrow/PBSC/T-cell donation.
Responsible physician: (printed name)
Date:
Signature:
(YYYY-MM-DD)
Name of collection/apheresis center:
SECTION B: TO BE COMPLETED BY THE TRANSPLANT CENTER
ADDITIONAL DONOR INFORMATION
I have received and reviewed the pre-collection (physical) examination test results and/or summaries from
the lead collection physician for this donor and I find that this volunteer stem cell donor is an acceptable
donor for stem cell collection.
First day of patient conditioning regimen:
(YYYY-MM-DD)
First collection date:
(YYYY-MM-DD)
Date of transplant:
(YYYY-MM-DD)
Transplant centre
contact person(s):
Telephone number:
24-hour telephone number:
Comments:
Person completing this form:
Date:
Signature:
(YYYY-MM-DD)
20160701-WGRE-FORM-F80
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