Stem cell forms

Collection 

FRM5071 and FRM1570-2B are required for all collections.  IF collections are taking place at NHSBT TAS units, FRM5110 and FRM3721 are required.

• FRM5110 (Word 372KB): Therapeutic Apheresis Services request form for collection of stem cells, lymphocytes or white cells
• FRM5071 (Word 41KB): Request to collect and process stem cell and immunotherapy products
• INF1243 (PDF 303KB): Guidance for the referral of patients for stem cell collection and processing, and using FRM5071
• FRM3721 (Word 57KB): TAS white cell collection final clearance
  
  

Testing 

• INF285- 2K (PDF 77KB): Guidance for healthcare professionals in consenting for the testing, storage and discard of stem cells or lymphocytes.
  
  

Consent

• FRM1570- 2B (PDF 240KB): Consent for the testing, storage and discard of stem cells or lymphocytes

Collection of cord blood for an intended recipient. Please send at least eight weeks before estimated due date.

• FRM1571- 2C (PDF 90KB): Request for directed collection
• FRM1572- 2D (PDF 139KB): Consent for directed collection, testing and cryopreservation
• INF286- 2L (PDF 110KB): Guidance for healthcare professionals in consenting for the collection, testing and cryopreservation for directed transplantation
• INF1153- 2R (PDF 80KB): Information for mothers regarding directed cord blood collection 

Please send requests at least two days prior to the start of conditioning.

Please note, if products are over five years old, a CFU assay may be required which takes up to three weeks to perform.

• FRM1599- 2F (PDF 51KB): Request for issue of products

• FRM1573 - 2G (Word) Engraftment report: 30 days post stem cell transplantation

• FRM1576 - 2M (PDF 114KB): Record of transfer of products between institutions
• FRM1577 - 2N (Word 54KB): Stem cell product return

• FRM1960 (Word 54KB): Request for authorisation to discard a HPC or other cellular therapy product