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
• INF1750 (PDF 120KB): Patient/Family information leaflet – Consent for Testing, Storage and Disposal of Cellular Therapy Products for Patients Undergoing Stem Cell Transplantation

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