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 407KB): 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): white cell collection final clearance
  
  

Testing 

• INF285 (PDF 77KB) guidance for healthcare professionals in consenting for the testing, storage and discard of stem cells or lymphocytes
  
  

Consent

• FRM1570 (Word 240KB): consent for testing, storage and disposal of cellular therapy products for patients undergoing stem cell transplantation
• INF1750 (PDF 120KB): patient/family information leaflet about consent for testing, storage and disposal of cellular therapy products for patients undergoing stem cell transplantation

The forms below cover the collection of cord blood, testing and cryopreservation. Please send at least eight weeks before the estimated due date.

• FRM1571- 2C (Word 90KB) - request form
• FRM1572 - 2D (Word 139KB)- consent form
• INF286 - 2L (PDF 110KB) - guidance for consent
• INF1153 - 2R (PDF 80KB) - information for mothers about 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 (Word 51KB): Request for issue of cryopreserved products

• FRM1573 - 2G (Word) Engraftment report: 30 days post stem cell transplantation
• INF1857 - Suggested Protocol to Manage Infusion Reaction Side Effects Reported to CMT (PDF 115KB) 

• 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