Re-Admission/HospitalizationForm (ADM)

Transcription

1 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): DateofAdmission(ADMITDT): Re-Admission/HospitalizationForm (ADM) WebVersion:1.0;4.02; Dateofdischarge:(DISCHDT) (mm/dd/yyyy) 2.Patientdischargestatus:(DISCPTST) 1-Alive 2-Dead IfDead,aDeathForm mustbesubmited. 3.RecordPRIMARYdischargediagnosis:(PHSPREAS) *Specifyorgan:(ADM4SPEC) **Specifyother:(ADM1SPEC) GVHD Relapse/Progression GraftFailure Infection FungalInfection? 4.Recordsecondarydischargediagnoses: a.gvhd:(reasgvhd) b.relapse/progression:(reasrlps) 1-Contributory ncontributory? 1-Contributory ncontributory c.graftfailure:(reasgf) 1-Contributory ncontributory d.infection:(reasinf) 1-Contributory ncontributory e.fever:(reasfvr) 1-Contributory ncontributory f.seizure:(reasszr) 1-Contributory ncontributory g.bleeding/hemorhage:(reasgibl) 1-Contributory ncontributory h.diarhea:(reasdrh) 1-Contributory ncontributory i.nausea/vomiting:(reasnv) 1-Contributory ncontributory j.organfailure:(reasorgf) 1-Contributory ncontributory Specifyorgan:(ADM3SPEC) k.trauma:(reastram) 1-Contributory ncontributory l.psychiatric:(reaspsyc) 1-Contributory ncontributory m.secondarymalignancy:(reasmalg) 1-Contributory ncontributory n.scheduledprocedure/treatment:(reasproc) 1-Contributory ncontributory o.thrombosis/thrombus/embolism:(reastrmb) 1-Contributory ncontributory p.other:(reasothr) Specifyother:(ADM2SPEC) 1-Contributory ncontributory 5.Recordre-admissioninstitution:(ADMCENTR) 1-1-OriginalTransplantCenter 2-2-OtherTransplantCenter 3-3-OtherHospital Comments:(ADMCOMM1)

2 AdditionalSelectionOptionsforADM RecordPRIMARYdischargediagnosis: Non-FungalInfection Fever Seizure Bleeding/Hemorhage Diarhea Nausea/Vomiting OrganFailure(specifyorgan)* Trauma Psychiatric SecondaryMalignancy Transplant ScheduledProcedure/Treatment Thrombosis/Thrombus/Embolism Other(specify)**

3 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): DateofOnset(ADVDATE): Eventdescription(ADVENT): Unexpected,Grade3-5AdverseEventForm (AE1) WebVersion:1.0;3.06; Reportactivationstatus:(AVSTATUS) IfOther,specifyreasonfordeactivation:(AESPEC1) 1-1-Keepreportactive 2-2-Deactivate-Reportfiledineror 3-3-Deactivate-Keyfielderor 9-9-Deactivate-Otherreason? 2.Recorddatetransplantcenterbecameawareoftheevent:(AVAWARDT) (mm/dd/yyyy) 3.Indicateweightattimeoftheevent:(AVWGHTKG) (xxx.x) kg 4.Wasthiseventexpectedoranticipated?(AVEXPECT) 5.Recordtheseverityofevent:(AVEVENT) 6.Whatistherelationshiptostudytherapy/intervention:(AVRELAT) 7.Isthereanalternativeetiology:(AVETIOL) 8.Whatistheefectonstudytherapy/interventionschedule:(AVEFFECT)? 1-1-Mild 2-2-Moderate 3-3-Severe 4-4-LifeThreatening 5-5-Fatal 1-1-Unrelated 2-2-Unlikely 3-3-Possible 4-4-Probable 5-5-Definite? 0-0-NoneApparent 1-1-StudyDisease 2-2-OtherPre-ExistingDiseaseorCondition 3-3-Accident,Trauma,orExternalFactors 4-4-ConcurentIlness/Condition(NotPre-Existing) 1-1-NoChange-Completed 2-Change-Ongoing 3-3-DoseModified 4-4-TemporarilyStopped 5-5-PermanentlyStopped 9.Recordthemostsevereoutcomeoftheevent:(AVOUTCOM) 1-1-Resolved,NoResidualEfects 2-2-ResolvedwithSequelae 3-3-PersistentCondition 4-4-ResolvedbyDeath 10.Recordthedateofresolution:(AVRESDT) (mm/dd/yyyy)? 11.Wasthiseventassociatedwith:(AVASSOCI) 0-0-NoneoftheFolowing 1-1-Death 2-2-Life-ThreateningEvent 3-3-Disability 4-4-CongenitalAnomaly??

4 Comments:(AE1COMM)

5 AdditionalSelectionOptionsforAE1 Wasthiseventassociatedwith: 5-5-RequiredInterventiontoPreventPermanentImpairmentorDamage 6-6-Hospitalization(InitialorProlonged) 9-9-OtherSAE

6 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): DateofOnset(ADVDATE): Eventdescription(ADVENT): SummaryForm -Unexpected,Grade3-5AdverseEvent(AE2) WebVersion:1.0;3.06; Reportactivationstatus:(AVSTAT_A) 1-1-Keepreportactive 2-2-Deactivate-Reportfiledineror 3-3-Deactivate-Keyfielderor 9-9-Deactivate-Otherreason RelevantPastMedicalHistory 2.Doesthepatienthaveanyrelevanthistory,includingpre-existingmedical conditions?(semedhxs) IfYes,includeanyrelevanthistory,includingpreexistingmedicalconditionsbelow. (SEMEDHX) 3.EventSummary Includeclinicalhistoryofevent,associatedsignsandsymptoms,alternativeetiologiesbeingconsideredandmedicalmanagementbelow. (SESUMM) 4.Initialsubmiter:(SEISUBBY) Name: Date:(SEISUBDT) (mm/dd /yyyy) 5.Authorizedsubmiter:(SEASUBBY) Name: Date:(SEASUBDT) (mm/dd /yyyy)?

7 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): DateofOnset(ADVDATE): Eventdescription(ADVENT): TherapyForm -Unexpected,Grade3-5AdverseEvent(AE3) WebVersion:1.0;3.06; Reportactivationstatus:(AVSTAT_B) 1-1-Keepreportactive 2-2-Deactivate-Reportfiledineror 3-3-Deactivate-Keyfielderor 9-9-Deactivate-Otherreason StudyProduct/SuspectMedicationData 2.Wasthepatientreceivinganystudyproducts/suspectmedications?(RCVSP) IfYes,listthestudyproduct/suspectmedicationsthesubjectwastakinginthegridbelow. StudyProductName (Note:Ifblinded,indicate assuch) Doseof StudyProduct(s) atsaeonset Routeof StudyProduct(s) atsae Onset Scheduleof StudyProduct(s) atsaeonset DateStudy Product FirstStarted (mm/dd/yyyy) DateStudy Product LastTaken (mm/dd/yyyy) ReasonforUse (SPNAME1) (SP1DOSE) (SP1ROUTE) (SP1SCHED) (SP1STDT) (SP1SPDT) (SP1REASO) (SPNAME2) (SP2DOSE) (SP2ROUTE) (SP2SCHED) (SP2STDT) (SP2SPDT) (SP2REASO) (SPNAME3) (SP3DOSE) (SP3ROUTE) (SP3SCHED) (SP3STDT) (SP3SPDT) (SP3REASO) (SPNAME4) (SP4DOSE) (SP4ROUTE) (SP4SCHED) (SP4STDT) (SP4SPDT) (SP4REASO) (SPNAME5) (SP5DOSE) (SP5ROUTE) (SP5SCHED) (SP5STDT) (SP5SPDT) (SP5REASO) ConcomitantMedications 3.Wasthepatienttakinganyconcomitantmedications?(RCVCONMD) IfYes,listtheconcomitantmedicationsthepatientwastakingupto1monthpriortoSAEonsetinthegridbelow. Medication StartDate (mm/dd/yyyy) StopDate (mm/dd/yyyy) Dose,Route,Schedule Indication (CONMED1) (CM1STDT) (CM1SPDT) (CM1DOSE) (CM1INDIC) 1-1-Treatmentofadverseevent 9-9-Other (CONMED2) (CM2STDT) (CM2SPDT) (CM2DOSE) (CM2INDIC) 1-1-Treatmentofadverseevent 9-9-Other (CONMED3) (CM3STDT) (CM3SPDT) (CM3DOSE) (CM3INDIC) 1-1-Treatmentofadverseevent 9-9-Other (CONMED4) (CM4STDT) (CM4SPDT) (CM4DOSE) (CM4INDIC) 1-1-Treatmentofadverseevent 9-9-Other (CONMED5) (CM5STDT) (CM5SPDT) (CM5DOSE) (CM5INDIC)

8 1-1-Treatmentofadverseevent 9-9-Other (CONMED6) (CM6STDT) (CM6SPDT) (CM6DOSE) (CM6INDIC) 1-1-Treatmentofadverseevent 9-9-Other (CONMED7) (CM7STDT) (CM7SPDT) (CM7DOSE) (CM7INDIC) 1-1-Treatmentofadverseevent 9-9-Other (CONMED8) (CM8STDT) (CM8SPDT) (CM8DOSE) (CM8INDIC) 1-1-Treatmentofadverseevent 9-9-Other (CONMED9) (CM9STDT) (CM9SPDT) (CM9DOSE) (CM9INDIC) 1-1-Treatmentofadverseevent 9-9-Other (CONMED10) (CM10STDT) (CM10SPDT) (CM10DOSE) (CM10INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED11) (CM11STDT) (CM11SPDT) (CM11DOSE) (CM11INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED12) (CM12STDT) (CM12SPDT) (CM12DOSE) (CM12INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED13) (CM13STDT) (CM13SPDT) (CM13DOSE) (CM13INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED14) (CM14STDT) (CM14SPDT) (CM14DOSE) (CM14INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED15) (CM15STDT) (CM15SPDT) (CM15DOSE) (CM15INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED16) (CM16STDT) (CM16SPDT) (CM16DOSE) (CM16INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED17) (CM17STDT) (CM17SPDT) (CM17DOSE) (CM17INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED18) (CM18STDT) (CM18SPDT) (CM18DOSE) (CM18INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED19) (CM19STDT) (CM19SPDT) (CM19DOSE) (CM19INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED20) (CM20STDT) (CM20SPDT) (CM20DOSE) (CM20INDI) 1-1-Treatmentofadverseevent 9-9-Other

9 (CONMED21) (CM21STDT) (CM21SPDT) (CM21DOSE) (CM21INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED22) (CM22STDT) (CM22SPDT) (CM22DOSE) (CM22INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED23) (CM23STDT) (CM23SPDT) (CM23DOSE) (CM23INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED24) (CM24STDT) (CM24SPDT) (CM24DOSE) (CM24INDI) 1-1-Treatmentofadverseevent 9-9-Other (CONMED25) (CM25STDT) (CM25SPDT) (CM25DOSE) (CM25INDI) 1-1-Treatmentofadverseevent 9-9-Other Comments:(AE3COMM)

10 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): DateofOnset(ADVDATE): Eventdescription(ADVENT): Laboratory/DiagnosticsForm -Unexpected,Grade3-5AdverseEvent(AE4) WebVersion:1.0;3.05; Reportactivationstatus:(AVSTAT_C) 1-1-Keepreportactive 2-2-Deactivate-Reportfiledineror 3-3-Deactivate-Keyfielderor 9-9-Deactivate-Otherreason LaboratoryTestResults 2.Wererelevantlaboratorytestsperformed?(LABTSTPF) IfYes,recordtherelevantlaboratorytestresultsinthegirdbelow. Test ColectionDate (mm/dd/yyyy) Result (Includeunits) SiteNormal Range (Includeunits) LabValuePrevious tothissae (Includeunits) ColectionDate forpreviouslab (mm/dd/yyyy) (ADLTST1) (ADL1CD) (ADL1RES) (ADL1NORG) (ADL1PRVL) (ADL1PCD) (ADLTST2) (ADL2CD) (ADL2RES) (ADL2NORG) (ADL2PRVL) (ADL2PCD) (ADLTST3) (ADL3CD) (ADL3RES) (ADL3NORG) (ADL3PRVL) (ADL3PCD) (ADLTST4) (ADL4CD) (ADL4RES) (ADL4NORG) (ADL4PRVL) (ADL4PCD) (ADLTST5) (ADL5CD) (ADL5RES) (ADL5NORG) (ADL5PRVL) (ADL5PCD) (ADLTST6) (ADL6CD) (ADL6RES) (ADL6NORG) (ADL6PRVL) (ADL6PCD) (ADLTST7) (ADL7CD) (ADL7RES) (ADL7NORG) (ADL7PRVL) (ADL7PCD) (ADLTST8) (ADL8CD) (ADL8RES) (ADL8NORG) (ADL8PRVL) (ADL8PCD) (ADLTST9) (ADL9CD) (ADL9RES) (ADL9NORG) (ADL9PRVL) (ADL9PCD) (ADLTST10) (ADL10CD) (ADL10RES) (ADL10NRG) (ADL10PVL) (ADL10PCD) DiagnosticTests(EX:MR,CTScan,Ultrasound) 3.Wererelevantdiagnostictestsperformed?(DXSTPF) IfYes,recordtherelevantdiagnostictestresultsinthegridbelow.Submitcopiesofthediagnostictestifavailable. Test DatePerformed (mm/dd/yyyy) Results/Comments

11 (ADDTS1) (AD1DTDAT) (AD1DTRES) (ADDTS2) (AD2DTDAT) (AD2DTRES) (ADDTS3) (AD3DTDAT) (AD3DTRES) (ADDTS4) (AD4DTDAT) (AD4DTRES) (ADDTS5) (AD5DTDAT) (AD5DTRES)

12 (ADDTS6) (AD6DTDAT) (AD6DTRES) (ADDTS7) (AD7DTDAT) (AD7DTRES) (ADDTS8) (AD8DTDAT) (AD8DTRES) (ADDTS9) (AD9DTDAT) (AD9DTRES) (ADDTS10) (AD10DTDT) (AD10DTRS)

13 Comments:(AE4COMM)

14 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): DateofOnset(ADVDATE): Eventdescription(ADVENT): Review Form -Unexpected,Grade3-5AdverseEvent(AE5) WebVersion:1.0;3.06; Reportactivationstatus:(AVSTAT_D) 1-1-Keepreportactive 2-2-Deactivate-Reportfiledineror 3-3-Deactivate-Keyfielderor 9-9-Deactivate-Otherreason 2.Reviewed:(AEREVIEW) 3.Reviewedby:(ARFREVBY) 4.Review date:(arfrevdt) (mm/dd/yyyy) 5.Comment1-ForDistribution:(ARCM1DIS) 6.Comment2-AlOtherReviewers/DataCoordinatingCenter(ARCM2ALL)

15 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): DateofOnset(ADVDATE): Eventdescription(ADVENT): MedicalMonitorReviewerForm -Unexpected,Grade3-5AdverseEvent(AE6) WebVersion:1.0;5.00; Adverseeventstatus:(AVSTAT_E) 1-1-Keepreportactive 2-2-Deactivate-Reportfiledineror 3-3-Deactivate-Keyfielderor 9-9-Deactivate-Otherreason 2.Hasthiseventbeendeterminedtobeanunexpected,grade3-5adverse event?(amdeter) 3.DoesthisrequireexpeditedreportingtotheDSMB?(AMEXPDSM) 4.Doyourecommendthepatientbewithdrawnfrom furtherprotocol therapy?(amwithdr) 5.Isthereviewcomplete?(AMREVDNE) 6.IfNo,whatadditionalinformationisrequired:(AMREVINF) 7.MedicalMonitoreventdescription:(AMMMEVDS) Comments:(AE6COMM)

16 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): VisitNumber(VISNO): Folow UpGVHD Form (CGV) WebVersion:1.0;7.03; Startofassessmentperiod:(DTPRVAST) (mm/dd/yyyy) 2.Endofassessmentperiod:(DTASSESS) (mm/dd/yyyy) Answerquestions3-9relatingtoacuteGVHD. 3.Maximum overalgradeofacutegvhd duringthis assessmentperiod:(grdagvhd) 0-0-NoSymptomsofAcuteGVHD 1-1-I 2-2-I 3-3-I 4-4-IV 4.Didclinicalsignsand/orsymptomsofacuteGVHDdevelop duringthisassessmentperiod?(agvdvlp) 5.Recordmethodusedtodiagnoseacute GVHD:(DGNSAGVH)? 1-1-HistologicEvidence 2-2-ClinicalEvidence 3-3-Both 6.DateofdiagnosisofacuteGVHD:(DTDGNAGV) (mm/dd/yyyy)? 7.WasprophylaxisforGVHD givenduringthisassessment period?(prophimm) DiscontinuedDuringThisAssessmentPeriod 8.Ifyes,specifyalimmunosuppressantsusedforGVHD prophylaxis: a.cyclosporine:(prophcy) b.tacrolimus:(prophtac) c.sirolimus:(prophsir) d.mmf:(prophmmf) e.prednisone:(prophprd) f.other:(prophoth) Specifyotheragentused:(PRPHOTSP) 9.IfGVHD prophylaxiswasdiscontinuedduringthis assessment,recordthedate:(prphdisc) (mm/dd/yyyy) Answerquestions10-20relatingtochronicGVHD. 10.Maximum overalseverityofchronicgvhd duringthis assessmentperiod:(sevcgvhd) 0-0-NoSymptomsofChronicGVHD 1-1-Mild 2-2-Moderate 3-3-Severe 11.Maximum overalgradeofchronicgvhd duringthis assessmentperiod:(grdcgvhd) 12.Didclinicalsignsand/orsymptomsofchronicGVHD develop duringthisassessmentperiod?(cgvdvlp) 13.Recordmethodusedtodiagnosechronic GVHD:(DGNSCGVH) 1-Limited 2-Extensive?? 1-1-HistologicEvidence 2-2-ClinicalEvidence 3-3-Both 14.DateofdiagnosisofchronicGVHD:(DTDGNCGV) (mm/dd/yyyy)?

17 15.Minimum Karnofsky/LanskyScoreattimeof diagnosis:(cgvkrnln) (Normal;NoComplaints/FulyActive) (NormalActivity/MinorRestrictioninStrenuousPlay) (NormalActivitywithEfort/RestrictedinStrenuousPlay) (UnabletoCaryOnNormalActivity/LessTimeSpentinPlay) (RequiresOccasionalAssistance/MinimalActivePlay) 16.Minimum plateletcountattimeofdiagnosis:(pltltcnt) (xxx.x) x10 9 /L 17.Alkalinephosphataseattimeofdiagnosis:(ALKPHOSP) (xxxx) U/L 18.Weightattimeofdiagnosis:(CGVWEIGH) (xxx.x) kg 19.Totalbilirubinattimeofdiagnosis:(BILIRUBN) (xx.x) mg/dl 20.Bodysurfaceareainvolvedwithrashattimeof diagnosis:(bsa) (xxx) %? Indicatethemaximum severityofinvolvementforthefolowingorgansystemsduringthisassessment period. Skin/Hair 21.Extentofskininvolvement:(CGVRASH) 0-0-NoRash 1-1-<25% ofbsainvolvement % ofbsainvolvement 3-3->50% ofbsainvolvement 4-4-GeneralizedInvolvement Ifthereisskininvolvement,indicatethetypeofrash: a.lichenoid:(rashlich)? b.maculopapular:(rashmacu) c.sclerodermatous:(rashsclr) Ocular 22.Xerophthalmia:(DRYEYES) 0-0-NoSymptoms 1-1-DryEyesbutNotRequiringTherapy 2-2-DrynessofEyesorInflammationRequiringTherapy Oral 23.Mucositis/ulcers(functional):(MUCOFXN) 0-0-NoSymptoms 1-1-MinimalSymptoms,NormalDiet 2-2-SymptomaticbutCanEatandSwalowModifiedDiet 3-3-SymptomaticandUnabletoAdequatelyAlimentorHydrateOraly Pulmonary 24.Dyspnea:(CGVDYSPN) 0-0-Asymptomatic 1-1-DyspneawithExertion 2-2-DyspneawithNormalActivities 3-3-DyspneaatRest 25.Pulmonaryfibrosis:(PULMFIBR) 0-0-None 1-1-MinimalRadiographicFindings 2-2-PatchyorBi-basilarRadiographicFindings 3-3-ExtensiveRadiographicFindings 9-9-NotDone 26.Bronchiolitisobliterans:(BRNCOBLT) 1-,Histologicdiagnosis 2-2-Yes,Clinicaldiagnosis 3-3-No 4-4-Unknown 27.FEV1:(CGVFEV1) % 1-1-<90-75% 2-2-<75-50% 3-3-<50-25% 4-4-<25%

18 28.Oxygensaturation:(O2SAT) 0-0-NoSymptoms 1-1-DesaturationwithExercise 2-2-RequiresSupplementalOxygen Gastrointestinal 29.Esophagus:(ESOPHAGS) 0-0-NoChanges 1-1-SymptomaticbutCanEatRegularDiet 2-2-DysphagiaorOdynophagiaRequiringDietaryChanges 3-3-NeedforParenteralNutrition 30.Nauseaandvomiting:(NAUSVOMT) 0-0-NoProtractedNauseaandVomiting 1-1-PersistentNausea,VomitingorAnorexia 31.Diarhea:(CGVDIARH) 0-0-None 1-1-PersistingLessThan2Weeks 2-2-PersistingMoreThan2Weeks 32.Wasdiarheameasuredasnumberofstoolsorvolumeof stools?(diarhmsr) 1-1-NumberofStools 2-2-VolumeofStools 3-3-BothNumberandVolume 33.Diarhea(numberofstools):(DIARHEA1) 1-1-Increaseof<4Stools/dayOverBaseline;MildIncreaseinOstomyOutputComparedtoBaseline 2-2-Increaseof4-6stools/day;IVFluidsIndicated<24Hrs;ModerateIncreaseinOstomyOutput 3-3-Increaseof7orMoreStools/day,IVFluidsfor24orMoreHrs;Hospitalization 4-4-Life-threateningConsequences(e.g.HemodynamicColapse) 5-5-Death UsemL/dayforadultrecipientsandmL/m 2 forpediatricrecipients. 34.Diarhea(volumeofstools):(DIARHEA2) 1-1-DiarheaLessThanorEqualto500mL/dayor<280mL/m^2 2-2-Diarhea>500butLessThanorEqualto1000mL/dayor mL/m^2 3-3-Diarhea>1000butLessThanorEqualto1500mL/dayor mL/m^2 4-4-Diarhea>1500mL/dayor>833mL/m^2 5-5-SevereAbdominalPainwithorwithoutIleus,orStoolwithFrankBloodorMelena 35.Malabsorption:(MALABSRP) 0-0-NoSymptoms 2-2-AlteredDiet;OralTherapiesIndicated(e.g.Enzymes,Medications,DietarySupplements) 3-3-InabilitytoAlimentAdequatelyviaGITract(e.g.TPN Indicated) 4-4-Life-threateningConsequences 5-5-Death Hepatic 36.Bilirubinlevel:(LIVERBIL) 0-0-Bilirubin<2.0mg/dL 1-1-Bilirubin mg/dL 2-2-Bilirubin mg/dL 3-3-Bilirubin mg/dL 4-4-Bilirubin>15.0mg/dL Genitourinary 37.Vaginitis:(VAGNITIS) 0-0-NoSymptomsorNotApplicable 1-1-Mild,InterventionNotIndicated 2-2-Moderate,InterventionIndicated 3-3-Severe,NotRelievedwithTreatment;Ulceration Musculoskeletal 38.Contractures:(CONTRCTR) 0-0-NoSymptoms 2-2-MildJointContractures(DoesnotAfectADL) 3-3-SevereJointContractures(InterfereswithADL) 39.Myositis:(MYOSITIS) Hematologic 40.Eosinophilia:(EOSINPHL)

19 Other 41.Serositis:(SEROSITS) 42.Fascitis:(FASCITIS) 43.Wasthereotherorganinvolvement?(ORGNOTHR) Specifyotherorgan:(ORGSPEC) Answerquestions44-50relatingtobiopsiesperformedduringthisassessmentperiod. 44.Wereanybiopsiesperformedduringthisassessmentperiod forsuspectedgvhd?(biopsy) Ifyes,recordthetype,date,andresultofanybiopsiesperformedforsuspectedGVHDbelow. TypeofBiopsy: IfOther,Specify: DateofBiopsy: ResultofBiopsy: 45.(BIOTYP1) 1-1-SkinBiopsy 2-2-OralBiopsy 3-3-UpperGIBiopsy 4-4-LowerGIBiopsy 5-5-LiverBiopsy (TYP1OSPE) (BIODT1) (mm/dd /yyyy) (BIORSLT1) 1-1-Positive 2-2-Negative 3-3-Equivocal 46.(BIOTYP2) 1-1-SkinBiopsy 2-2-OralBiopsy 3-3-UpperGIBiopsy 4-4-LowerGIBiopsy 5-5-LiverBiopsy (TYP2OSPE) (BIODT2) (mm/dd /yyyy) (BIORSLT2) 1-1-Positive 2-2-Negative 3-3-Equivocal 47.(BIOTYP3) 1-1-SkinBiopsy 2-2-OralBiopsy 3-3-UpperGIBiopsy 4-4-LowerGIBiopsy 5-5-LiverBiopsy (TYP3OSPE) (BIODT3) (mm/dd /yyyy) (BIORSLT3) 1-1-Positive 2-2-Negative 3-3-Equivocal 48.(BIOTYP4) 1-1-SkinBiopsy 2-2-OralBiopsy 3-3-UpperGIBiopsy 4-4-LowerGIBiopsy 5-5-LiverBiopsy (TYP4OSPE) (BIODT4) (mm/dd /yyyy) (BIORSLT4) 1-1-Positive 2-2-Negative 3-3-Equivocal 49.(BIOTYP5) 1-1-SkinBiopsy 2-2-OralBiopsy 3-3-UpperGIBiopsy 4-4-LowerGIBiopsy 5-5-LiverBiopsy (TYP5OSPE) (BIODT5) (mm/dd /yyyy) (BIORSLT5) 1-1-Positive 2-2-Negative 3-3-Equivocal 50.(BIOTYP6) 1-1-SkinBiopsy 2-2-OralBiopsy 3-3-UpperGIBiopsy 4-4-LowerGIBiopsy 5-5-LiverBiopsy (TYP6OSPE) (BIODT6) (mm/dd /yyyy) (BIORSLT6) 1-1-Positive 2-2-Negative 3-3-Equivocal Answerquestions51-54relatingtoGVHD therapy.

20 51.WasaspecifictherapyusedtotreatGVHD duringthis assessmentperiod?(thrpyusd) 1-,InitiatedthisAssessmentPeriod 2-2-Yes,Continuingfrom PreviousAssessmentPeriod 3-3-No? Ifyes,indicatewhetherornottheagentslistedbelowwereusedtotreatGVHD duringthisassessmentperiod: a.als,alg,ats,atg:(thrpyatg) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven b.azathioprine:(thrpyaza) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven c.cyclosporine:(thrpycyc) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven d.systemiccorticosteroids:(thrpysco) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven e.topicalcorticosteroids:(thrpytco) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven f.thalidomide:(thrpytha) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven g.tacrolimus(fk 506,Prograf):(THRPYTAC) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven h.mycophenolatemofetil(mmf,celcept):(thrpymmf) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven i.puva(psoralenanduva):(thrpypuv) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven j.ecp(extra-corporealphotopheresis):(thrpyecp) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven k.sirolimus(rapamycin):(thrpysir) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven l.etretinate:(thrpyetr) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven m.lamprene:(thrpylam) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven n.etanercept:(thrpyeta) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven o.zenapax(daclizumab):(thrpyzen) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven p.chloroquinephosphate:(thrpycph) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven

21 q.invivoantit-lymphocytemonoclonal Antibody:(THRPYMAB) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven SpecifyinvivoantiT-lymphocytemonoclonalantibody used:(mabagnt) r.invivoimmunotoxin:(thrpyimm) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven Specifyinvivoimmunotoxinused:(IMMAGNT) s.other:(thrpyoth) 1-,StilTakingDrug 2-2-Yes,NoLongerTakingDrug 3-3-No,DrugNotGiven Specifyotheragentused:(OTHAGNT) 52.Hastreatmentbeendiscontinued?(ONGTRT) 53.Ifyes,enterdateofdiscontinuation:(TRTSTOP) (mm/dd/yyyy) 54.IndicatethebestresponsetoGVHD therapyduringthis assessmentperiod:(thrpyrsp) 1-1-CompleteResolutionofSymptoms 2-2-PartialResolutionofSymptoms 3-3-StableSymptoms 4-4-ProgressionofSymptoms? Answerquestions55-58relatingtocurrentpatientstatus. 55.AresymptomsofGVHD stilpresent?(gvhdsymp) 56.CurentKarnofsky/LanskyScore:(CURKRNLN) (Normal;NoComplaints/FulyActive) (NormalActivity/MinorRestrictioninStrenuousPlay) (NormalActivitywithEfort/RestrictedinStrenuousPlay) (UnabletoCaryOnNormalActivity/LessTimeSpentinPlay) (RequiresOccasionalAssistance/MinimalActivePlay) 57.Curentplateletcount:(CURPLTCT) (xxx.x) x10 9 /L 58.Curentweight:(CURWGHT) (xxx.x) kg Comments:(CGVCOMM)

22 AdditionalSelectionOptionsforCGV Minimum Karnofsky/LanskyScoreattimeofdiagnosis: (RequiresConsiderableAssistance/NoActivePlay) (Disabled/AbletoInitiateQuietActivities) (SeverelyDisabled/NeedsAssistanceforQuietPlay) (VerySick/LimitedtoVeryPassiveActivity) (Moribund;CompletelyDisabled) BiopsyType1 6-6-LungBiopsy 7-7-Other,Specify CurentKarnofsky/LanskyScore: (RequiresConsiderableAssistance/NoActivePlay) (Disabled/AbletoInitiateQuietActivities) (SeverlyDisabled/NeedsAssistanceforQuietPlay) (VerySick/LimitedtoVeryPassiveActivity) (Moribund;CompletelyDisabled) (Dead)

23 BloodandMarrow TransplantClinical TrialsNetwork Demographics(DEM) WebVersion:1.0;6.00; NameCode:(NAMECODE) 2.IUBMID #(ifavailable):(iubmid) 3.CRID #(CIBMTRRecipientID):(CRIDNUM) (xxxxxxxxxx) 4.Gender:(GENDER) DoNOTuseIUBMID/UPN numbersinthecridfield. 1-Male 2-Female 5.DateofBirth:(DOB) (mm/dd/yyyy) 6.Ethnicity:(ETHNIC) 1-1-HispanicorLatino 2-tHispanicorLatino 8-8-Unknown 9-9-NotAnswered 7.Race:(RACE) -White White(NotOtherwiseSpecified) European(NotOtherwiseSpecified) Mediteranean WhiteNorthAmerican Specifyrace:(RACESP) 8.SecondaryRace:(RACE2) -White White(NotOtherwiseSpecified) European(NotOtherwiseSpecified) Mediteranean WhiteNorthAmerican Specifysecondaryrace:(RACE2SP) Comments:(DEMCOMM1)

24 AdditionalSelectionOptionsforDEM Race: SouthorCentralAmerican EasternEuropean NorthernEuropean WesternEuropean WhiteCaribbean 82-8rthCoastofAfrica MiddleEastern -Black Black(NotOtherwiseSpecified) AfricanAmerican AfricanBlack(BothParentsBorninAfrica) CaribbeanBlack SouthorCentralAmericanBlack Black,OtherSpecify -Asian Asian(NotOtherwiseSpecified) Indian/SouthAsian Filipino(Pilipino) Japanese Korean Chinese OtherSoutheastAsian Vietnamese -AmericanIndianorAlaskaNative NativeAmerican(NotOtherwiseSpecified) NativeAlaskan/Eskimo/Aleut AmericanIndian(NotOtherwiseSpecified) NorthAmericanIndian SouthorCentralAmericanIndian CaribbeanIndian -NativeHawaianorOtherPacificIslander NativePacificIslander(NotOtherwiseSpecified) Guamanian Hawaian Samoan -Other Unknown Other,Specify NotAnswered

25 BloodandMarrow TransplantClinical TrialsNetwork DeathForm (DTH) WebVersion:1.0;4.06; Recorddateofdeath:(DTHDT) (mm/dd/yyyy) 2.Wasanautopsyperformed?(AUTPERF) Ifyes,submitautopsyreporttoDCC Enterappropriatecauseofdeathcodebelow.Listinorderofdecreasingseverity. 3.Primarycauseofdeath:(CZDTHPRM) GraftRejectionorFailure -Infection(OtherthanInterstitialPneumonia) AutologousRecovery Rejection Bacterial? Specifyother:(DTHSPEC1) 4.Secondarycauseofdeath:(SCNDCZ1) GraftRejectionorFailure -Infection(OtherthanInterstitialPneumonia) AutologousRecovery Rejection Bacterial Specifyother:(DTHSPEC2) 5.Secondarycauseofdeath:(SCNDCZ2) GraftRejectionorFailure -Infection(OtherthanInterstitialPneumonia) AutologousRecovery Rejection Bacterial Specifyother:(DTHSPEC3) 6.Secondarycauseofdeath:(SCNDCZ3) GraftRejectionorFailure -Infection(OtherthanInterstitialPneumonia) AutologousRecovery Rejection Bacterial Specifyother:(DTHSPEC4) 7.Secondarycauseofdeath:(SCNDCZ4) GraftRejectionorFailure -Infection(OtherthanInterstitialPneumonia) AutologousRecovery Rejection Bacterial Specifyother:(DTHSPEC5) Comments:(DTCMMNTS)

26 AdditionalSelectionOptionsforDTH Primarycauseofdeath: Fungal Viral Protozoal Other,SpecifyBelow Organism NotIdentified -InterstitialPneumonia Viral,CMV Viral,Other Pneumocystis Other,SpecifyBelow Idiopathic AdultRespiratoryDistressSyndrome AcuteGVHD ChronicGVHD RecurenceorPersistenceofLeukemia/Malignancy/MDS PersistentDisease -OrganFailure(NotDuetoGVHDorInfection) Liver Cardiac(Cardiomyopathy) Pulmonary CNS Renal Other,SpecifyBelow MultipleOrganFailure,SpecifyBelow SecondaryGraftFailure SecondaryMalignancy EBV Other,SpecifyBelow -Hemorhage Pulmonary Intracranial Gastrointestinal HemorhageNotSpecified Other,SpecifyBelow -Vascular Thromboembolic DisseminatedIntravascularCoagulation(DIC) Gastrointestinal ThromboticThrombocytopenicPurpura VascularNotSpecified Other,SpecifyBelow AccidentalDeath Other,SpecifyBelow

27 BloodandMarrow TransplantClinical TrialsNetwork 0402A(ENR) WebVersion:1.0;6.02; GVHD Prophylaxis-SegmentA 1.Recordthedatepatient'sinformedconsentform was signed:(cn0402dt) (mm/dd/yyyy) 2.Patient'sbirthdate:(PTDBTDT) (mm/dd/yyyy) 3.Recordtheproposedstartdateofconditioning:(CONDDT) (mm/dd/yyyy) 4.Conditioningregimen:(CONDREG) 1-1-CyclophosphamideandTotalBodyIradiation(CY-TBI) 2-2-EtoposideandTotalBodyIradiation(VP16-TBI) InclusionCriteria 5.Recordtheparticipant'sprimarydiagnosis:(PRIMDX) 6.IfAML,recordthediseasestage:(AML402SG) 7.IfALL,recordthediseasestage:(ALL402SG) 8.IfCML,recordthediseasestage:(CML402SG) 9.IfMDS,recordthediseasestage:(MDS402SG) 10.IfAcuteBiphenotypicLeukemia,recordthedisease stage:(abl402sg) 11.IfAcuteBiphenoytpicLeukemia,perwhichhistologywasthe patientbeingtreated?(abl402ht) 1-1-AcuteMyelogenousLeukemia(AML) 2-2-AcuteLymphoblasticLeukemia(ALL) 3-3-ChronicMyelogenousLeukemia(CML) 4-4-MyelodysplasticSyndrome(MDS) 5-5-AcuteBiphenotypicLeukemia 1-1-FirstRemission 2-2-SecondRemission 3-3-SubsequentRemission 1-1-FirstRemission 2-2-SecondRemission 3-3-SubsequentRemission 1-1-ChronicPhase 2-2-AcceleratedPhase 1-1-RefractoryAnemia 2-2-RefractoryAnemiawithRingedSideroblasts 3-3-RefractoryCytopeniawithMultilineageDysplasia 4-4-RefractoryCytopeniawithMultilineageDysplasiaandRingedSideroblasts 5-5-RefractoryAnemiawithExcessBlasts1(5-10% blasts) 1-1-FirstRemission 2-2-SecondRemission 3-3-SubsequentRemission 1-1-AcuteMyelogenousLeukemia(AML) 2-2-AcuteLymphoblasticLeukemia(ALL) 12.Performancestatusscaleusedtoevaluatepatient(Lanskyfor patients<16yearsold;karnofskyforpatients>16years old):(ptkarlan) 13.Recordthepatient'sperformancestatus:(PTKLSCR) 14.Ifthepatientis<18yearsold,indicateifhe/sheiswilingandableto takeoralmedications:(oralmed) 1-Karnofsky 2-Lansky (Normal;NoComplaints/FulyActive) (NormalActivity/MinorRestrictioninStrenuousPlay) (NormalActivitywithEfort/RestrictedinStrenuousPlay) (UnabletoCaryOnNormalActivity/LessTimeSpentinPlay) (RequiresOccasionalAssistance/MinimalActivePlay) 3-NotApplicable MostRecentValue LLNforyourInstitution ULN foryourinstitution DateSampleObtained

28 15. Serum Creatinine: (SCRESCR) (x.x) mg/dl (SCRELLN) (x.x) mg/dl (SCREULN) mg/dl (x.x) (SCREDT) (mm/dd/yyyy) 16. CalculatedCreatinine Clearance: (CRECLSCR) (xxx) ml/min N/A N/A (CRECLDT) (mm/dd/yyyy) 17. DirectBilirubin: (BILISCR) (x.x) mg/dl 18. ALT: (ALTSCR) (xxx) Units/L N/A (BI402ULN) (x.x) mg/dl N/A (AL402ULN) (xx) Units/L (BILIDT) (mm/dd/yyyy) (ALTDAT) (mm/dd/yyyy) 19. AST: (ASTSCR) (xxx) Units/L N/A (AS402ULN) (xxx) Units/L (ASTDAT) (mm/dd/yyyy) 20. Cholesterol: (CHOLSCR) (xxx) mg/dl 21. Triglycerides: (TRIGSCR) (xxx) mg/dl N/A N/A (CHOLDT) (mm/dd/yyyy) N/A N/A (TRIGDT) (mm/dd/yyyy) 22.Werepulmonaryfunctiontestsperformed?(PULFTST) IfPFT'swerenotperformed,thenanO 2saturationmustbeobtained. MostRecentValueCorectedforHemoglobin DateSampleObtained 23. FVC: (FVCSCR) (xxx) % ofpredictedvalue (FVCDAT) (mm/dd/yyyy) 24. FEV1: (FEV1SCR) (xxx) % ofpredictedvalue (FEV1DAT) (mm/dd/yyyy) 25.O2saturationonroom air:(o2sattst) (xxx) % DateO 2saturationwasobtained:(O2SATDT) (mm/dd/yyyy) 26.Recordthetypeoffractiontestperformed:(FR0402TY) 1-1-LeftVentricularEjectionFraction(LVEF) 2-2-ShorteningFraction 27.Recordtheleftventricularejectionfraction:(EJTFRSCR) (xxx) % Dateejectionfractionperformed:(EJTFRDT) (mm/dd/yyyy) 28.Recordtheshorteningfractionatrest:(SHTFRSCR) (xxx) % Dateshorteningfractionperformed:(SHTFRDT) (mm/dd/yyyy) ExclusionCriteria 29.Hastheparticipanthadaprioralogeneicorautologous transplant?(priortxp) 30.IsthepatientHIVseropositive?(HIVSCR) 31.Isthepatientdiagnosedwithanuncontroledviral,bacterial,orfungal infection?(vibafuif) 32.Isthepatientpregnant(positiveserum orurineβ-hcg)orbreast feeding?(pregscr) 33.Doesthepatienthaveadocumentedalergyto Sirolimus?(SIROALG) 34.IsthepatientcurentlyreceivingVoriconazole?(VORIRX) 35.Isthepatientreceivinganinvestigationaldrug?(INVSDG) 3-NotApplicable Yes,ApprovedbyStudyChair/MM 3-3-No 36.Dateapprovedbystudychair/medicalmonitor:(DGAPPDT) (mm/dd/yyyy) 37.Doesthepatienthaveahistoryofpriormalignanciesotherthan resectedbasalcelcarcinoma,treatedcarcinomainsituorcancer treatedwithcurativeintent>5yearspreviously?(maligscr) 38.Doesthepatienthaveacancertreatedwithcurativeintent<5years previously?(malig5yr) Yes,ApprovedbyStudyChair/MM 3-3-No 39.Dateapprovedbystudychair/medicalmonitor:(MAAPPDT) (mm/dd/yyyy) HLATyping TypeofHLAMatchrequiredbythisprotocol:(HLAMATCH) DNA_HIGH-HighLevelDNA DNA_LOW-Low LevelDNA SEROLOGY-Serologic AB_SEROLOGY_DRB1_DNA_LOW-LociA,B:Serologic,LocusDRB1:LowLevelDNA AB_DNA_LOW_DRB1_DNA_HIGH-LociA,B:LowLevelDNA,LocusDRB1:HighLevelDNA

29 40. RecipientHLATyping HLA-A Typingmethod:(RHLAAMET) Antigens/alelesprovided:(RHLAANUM) 1-1-DNATechnology 2-2-Serology 1-1-One 2-2-Two 1st: (RHLAA11X) (RHLAA12X) / (RHLAA13X) / (RHLAA14X) / (RHLAA15X) (RHLAA16X) / (RHLAA17X) / (RHLAA18X) / 2nd: (RHLAA21X) (RHLAA22X) / (RHLAA23X) / (RHLAA24X) / (RHLAA25X) (RHLAA26X) / (RHLAA27X) / (RHLAA28X) / HLA-B Typingmethod:(RHLABMET) Antigens/alelesprovided:(RHLABNUM) 1-1-DNATechnology 2-2-Serology 1-1-One 2-2-Two 1st: (RHLAB11X) (RHLAB12X) / (RHLAB13X) / (RHLAB14X) / (RHLAB15X) (RHLAB16X) / (RHLAB17X) / (RHLAB18X) / 2nd: (RHLAB21X) (RHLAB22X) / (RHLAB23X) / (RHLAB24X) / (RHLAB25X) (RHLAB26X) / (RHLAB27X) / (RHLAB28X) / HLA-DRB1 Typingmethod:(RHLADMET) Antigens/alelesprovided:(RHLADNUM) 1-1-DNATechnology 2-2-Serology 1-1-One 2-2-Two 1st: (RHLAD11X) (RHLAD12X) / (RHLAD13X) / (RHLAD14X) / (RHLAD15X) (RHLAD16X) / (RHLAD17X) / (RHLAD18X) / 2nd: (RHLAD21X) (RHLAD22X) / (RHLAD23X) / (RHLAD24X) / (RHLAD25X) (RHLAD26X) / (RHLAD27X) / (RHLAD28X) / 41. DonorHLATyping HLA-A Typingmethod:(DHLAAMET) Antigens/alelesprovided:(DHLAANUM) 1-1-DNATechnology 2-2-Serology 1-1-One 2-2-Two 1st: (DHLAA11X) (DHLAA12X) / (DHLAA13X) / (DHLAA14X) / (DHLAA15X) (DHLAA16X) / (DHLAA17X) / (DHLAA18X) / 2nd: (DHLAA21X) (DHLAA22X) / (DHLAA23X) / (DHLAA24X) / (DHLAA25X) (DHLAA26X) / (DHLAA27X) / (DHLAA28X) / HLA-B Typingmethod:(DHLABMET) Antigens/alelesprovided:(DHLABNUM) 1-1-DNATechnology 2-2-Serology 1-1-One 2-2-Two 1st: (DHLAB11X) (DHLAB12X) / (DHLAB13X) / (DHLAB14X) / (DHLAB15X) (DHLAB16X) / (DHLAB17X) / (DHLAB18X) /

30 2nd: (DHLAB21X) (DHLAB22X) / (DHLAB23X) / (DHLAB24X) / (DHLAB25X) (DHLAB26X) / (DHLAB27X) / (DHLAB28X) / HLA-DRB1 Typingmethod:(DHLADMET) 1-1-DNATechnology 2-2-Serology Antigens/alelesprovided:(DHLADNUM) 1-1-One 2-2-Two 1st: (DHLAD11X) (DHLAD12X) / (DHLAD13X) / (DHLAD14X) / (DHLAD15X) (DHLAD16X) / (DHLAD17X) / (DHLAD18X) / 2nd: (DHLAD21X) (DHLAD22X) / (DHLAD23X) / (DHLAD24X) / (DHLAD25X) (DHLAD26X) / (DHLAD27X) / (DHLAD28X) / Locus-AcalculatedHLAMatchScore(SCORE_A) Locus-BcalculatedHLAMatchScore(SCORE_B) Locus-DRB1calculatedHLAMatchScore(SCORE_D) TotalcalculatedHLAMatchScore(HLASCORE) DoyouagreewiththecalculatedHLAMatchScore?(HLAAGREE) Indicateyourinstitution'sHLAMatchScoreforthis participant:(sitescr) 0/6-0/6 1/6-1/6 2/6-2/6 3/6-3/6 4/6-4/6 Comments(COMMENTS)

31 AdditionalSelectionOptionsforENR IfMDS,recordthediseasestage: 6-6-RefractoryAnemiawithExcessBlasts-2(10-20% blasts) 7-7-MyelodysplasticSyndrome,Unclassified 8-8-MDSAssociatedwithIsolatedDel(5q) 9-9-ChronicMyelomonocyticLeukemia Recordthepatient'sperformancestatus: (RequiresConsiderableAssistance/NoActivePlay) (Disabled/AbletoInitiateQuietActivities) (SeverelyDisabled/NeedsAssistanceforQuietPlay) (VerySick/LimitedtoVeryPassiveActivity) (Moribund;CompletelyDisabled) TypeofHLAMatchrequiredbythisprotocol: AB_SEROLOGY_DRB1_DNA_HIGH-LociA,B:Serologic,LocusDRB1:HighLevelDNA ABC_DNA_LOW_DRB1_DNA_HIGH-LociA,B,C:LowLevelDNA,LocusDRB1:HighLevelDNA ABCDQ_DNA_LOW_DRB1_DNA_HIGH-LociA,B,C,DQ:Low LevelDNA,LocusDRB1:HighLevelDNA Indicateyourinstitution'sHLA MatchScoreforthisparticipant: 5/6-5/6 6/6-6/6 0/8-0/8 1/8-1/8 2/8-2/8 3/8-3/8 4/8-4/8 5/8-5/8 6/8-6/8 7/8-7/8 8/8-8/8

32 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): VisitNumber(VISNO): Folow UpStatusForm (FUS) WebVersion:1.0;12.01; Dateoflastcontact:(LASTCTDT) (mm/dd/yyyy) Sincethedateofthelastvisitindicateifanyofthefolowinghaveoccurred: 2.Hasthepatientdied?(DIED) IfYes,aDeathForm mustbesubmited. 3.Dateofpatientdeath:(DEATHDT) (mm/dd/yyyy) 4.Hasthepatientrelapsedorexperienceddiseaseprogression?(RELAPSE) IfYes,aRelapseForm mustbesubmited. 5.Dateofrelapseorprogression:(RELAPSDT) (mm/dd/yyyy) 6.Hasthepatientexperiencedsecondarygraftfailure?(SECGRFAL) 7.Hasthepatientexperiencedsecondarygraftfailure?(SECGRFAL) IfYes,aSecondaryGraftFailureForm mustbesubmited. 8.Dateofsecondarygraftfailure:(SCGRFLDT) (mm/dd/yyyy) 9.Dateofsecondarygraftfailure:(SCGRFLDT) (mm/dd/yyyy) Hasthepatientexperiencedanynew clinicalysignificantinfections?(newinfx) IfYes,anInfectionForm mustbesubmited. 12.Dateofinfection:(INFDT) (mm/dd/yyyy) 13.Hasthepatientbeenhospitalized?(HOSPITAL) 14.Dateofhospitalization:(HOSPTLDT) IfYes,aRe-AdmissionForm mustbesubmited. (mm/dd/yyyy) 15.Hasthepatientreceivedanon-protocolspecifiedtransplant?(TRANSTWO) 16.Dateofnon-protocolspecifiedtransplant:(DATRANSP) (mm/dd/yyyy) Comments:(FUS1COMM)

33 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): VisitNumber(VISNO): AcuteGVHDForm (GVH) WebVersion:1.0;10.04; Dateofstaging:(STAGEDT) (mm/dd/yyyy) StartofGVHD AssessmentPeriod:(GVASSTDT) (mm/dd/yyyy) EndofGVHD AssessmentPeriod:(GVASENDT) (mm/dd/yyyy) 2.Recordthestudydrugassignment:(GVHTRAS) 1-Sirolimus/Tacrolimus 2-Tacrolimus/Methotrexate Theassessmentforwhichyouareenteringdatamusthavetakenplacewithintheabovedates.Ifthepatientwasnotseenduringtheassessmentperiodspecifiedabove, pleaseexittheform andrequestanexceptionforthisform. 3.Immunosuppressant(prophylaxis)received:(IMMUNORC) 0-0-Prednisone 1-1-Cyclosporine 2-2-Tacrolimus 3-3-Nottakenduringassessment 4.Recordmostrecentbloodlevelofimmunosuppressant (prophylaxis):(troughlv) (xxxx.x) ng/ml 5.Recorddatebloodsampleobtained:(TROUGHDT) (mm/dd/yyyy)? 6.Recordmostrecentbloodlevelofsirolimus:(GVHSIRLV) (xxxx.x) ng/ml 7.Recorddatebloodsampleobtained:(GVHSIRDT) (mm/dd/yyyy) Recordthehighestleveloforganabnormalities,theetiologiescontributingtotheabnormalitiesandanybiopsyresultsduringtheassessmentperiod. 8.Skinabnormalities:(GVHSKINA) 9.Skinetiologies: 0-0-NoRash 1-1-MaculopapularRash,<25% ofbodysurface 2-2-MaculopapularRash,25-50% ofbodysurface 3-3-GeneralizedErythroderma 4-4-GeneralizedErythrodermawithBulusFormationandDesquamation? GVHD DrugReaction ConditioningRegimenToxicity (SETGVHD)? (SETDRGRX) (SETCRTOX) Infection Other (SETINFCT) (SETOTHER) Specifyotherskinetiologies:(GVHSKNSP) 10.SkinbiopsyforGVHD:(GVHSKINB) 1-1-Positive 2-2-Negative 3-3-Equivocal 4-4-NotDone 11.UpperGIabnormalities:(GVHUPGIA) 0-0-NoProtractedNauseaandVomiting 1-1-PersistentNausea,VomitingorAnorexia 12.Upperintestinaltractetiologies: GVHD DrugReaction ConditioningRegimenToxicity (UGIETGVH) (UGIETDRG) (UGIETCON) TPN Infection Other (UGIETTPN) (UGIETINF) (UGIETOTH)

34 Specifyotherupperintestinaltractetiologies:(UGIETSPC) 13.UpperintestinaltractbiopsyforGVHD:(UGIBIORS) 1-1-Positive 2-2-Negative 3-3-Equivocal 4-4-NotDone 14.LowerGIabnormalities:(GVHINTA) 0-0-NoDiarhea 1-1-DiarheaLessThanorEqualto500mL/dayor<280mL/m^2 2-2-Diarhea>500butLessThanorEqualto1000mL/dayor mL/m^2 3-3-Diarhea>1000butLessThanorEqualto1500mL/dayor mL/m^2 4-4-Diarhea>1500mL/dayor>833mL/m^2? 15.Lowerintestinaltractetiologies: UsemL/dayforadultpatientsandmL/m 2 forpediatricpatients GVHD DrugReaction ConditioningRegimenToxicity (LGIETGVH) (LGIETDRG) (LGIETCON) TPN Infection Other (LGIETTPN) (LGIETINF) (LGIETOTH) Specifyotherlowerintestinaltractetiologies:(LGIETSPC) 16.LowerintestinaltractbiopsyforGVHD:(LGIBIORS) 1-1-Positive 2-2-Negative 3-3-Equivocal 4-4-NotDone 17.Liverabnormalities:(GVHLIVRA) 0-0-Bilirubin<2.0mg/dL 1-1-Bilirubin mg/dL 2-2-Bilirubin mg/dL 3-3-Bilirubin mg/dL 4-4-Bilirubin>15.0mg/dL 18.Liveretiologies: GVHD DrugReaction ConditioningRegimenToxicity TPN (LIVETGVH) (LIVETDRG) (LIVETCND) (LIVETTPN) Infection VOD Other (LIVETINF) (LIVETVOD) (LIVETOTH) Specifyotherliveretiologies:(GVHLIVRS) 19.LiverbiopsyforGVHD:(GVHLIVRB) 1-1-Positive 2-2-Negative 3-3-Equivocal 4-4-NotDone ')} ThisonlyappliestoTREATMENTforGVHD.IfGVHD prophylaxiswastheonlymodificationduringthisassessmentperiod,thisquestionshouldbeanswered"". 20.Ifyes,specifyagentname:(GVHAGENT) 1-1-CSA 2-2-FK TopicalSteroids 4-4-Prednisone 5-5-ATG Specifyotheragent:(GVHAGNSP)

35 21.Indicatetreatmentmodification:(GVHTRMOD) 1-1-Started 2-2-Stopped 4-4-Tapered 5-5-Increased Comments:(GVHCOMM)

36 AdditionalSelectionOptionsforGVH LowerGIabnormalities: 5-5-SevereAbdominalPainwithorwithoutIleus,orStoolwithFrankBloodorMelena Ifyes,specifyagentname: 6-6-MMF 7-7-Daclizumab 8-8-Methylprednisolone 9-9-Other

37 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): VisitNumber(VISNO): MyeloablativeHematopoiesisForm (HEM) WebVersion:1.0;7.01; DidthepatientachieveANC recovery>500/mm 3 onthreeconsecutive days?(engrft1) 3-PreviouslyReported 2.Recordneutrophilcountandspecimencolectiondates: Day1: (ANCDAY1) (xxxxx) /mm 3 (ANC1DT) (mm/dd/yyyy) Day2: (ANCDAY2) (xxxxx) /mm 3 (ANC2DT) (mm/dd/yyyy) Day3: (ANCDAY3) (xxxxx) /mm 3 (ANC3DT) (mm/dd/yyyy) RecordChimerism AssayDataforMarrow and/orblood Marow 3.Wasachimerism performedonamarowsample?(mrwdone) 4.Datespecimencolected:(MRWDT2) (mm/dd/yyyy) 5.Methodofevaluation:(MTHOD1) 1-1-StandardCytogenetics 2-2-FluorescentInSituHybridization(FISH) 3-3-RestrictionFragment-LengthPolymorphisms(RFLP) 4-4-PolymeraseChainReaction(PCR) 5-5-HLASerotyping Specifyother:(MRWSPEC) 6.Celtype:(MRWCLTYP) 7.Marowassayresults:(MRWASSAY) 1-Unmanipulated 1-1-AlHostCels 2-2-AlDonorCels 3-3-HostandDonor 2-Granulocytes 8.% Donor:(PCNTDNR1) (xx) % Blood 9.Wasachimerism performedonabloodsample?(blddone) 10.Datespecimencolected:(BLDCHMDT) 11.Methodofevaluation:(MTHOD2) (mm/dd/yyyy) 1-1-StandardCytogenetics 2-2-FluorescentInSituHybridization(FISH) 3-3-RestrictionFragment-LengthPolymorphisms(RFLP) 4-4-PolymeraseChainReaction(PCR) 5-5-HLASerotyping Specifyother:(BLDSPEC) 12.Celtype:(BLDCLTYP) 13.Bloodassayresults:(BLDASSAY) 1-Unmanipulated 1-1-AlHostCels 2-2-AlDonorCels 3-3-HostandDonor 2-Granulocytes 14.% Donor:(PCNTDNR2) (xx) % TCelChimerism 15.Wasachimerism performedonatcelsample?(tcldone) 16.Typeofsample:(TCLSMPL) 1-Blood 2-Marow 17.Datespecimencolected:(TCLDATE) (mm/dd/yyyy)

38 18.Methodofevaluation:(MTHOD3) 1-1-StandardCytogenetics 2-2-FluorescentInSituHybridization(FISH) 3-3-RestrictionFragment-LengthPolymorphisms(RFLP) 4-4-PolymeraseChainReaction(PCR) 5-5-HLASerotyping Specifyother:(TCLSPEC) 19.Tcelassayresults:(TCLASSAY) 1-1-AlHostCels 2-2-AlDonorCels 3-3-HostandDonor 20.% Donor:(PCNTDNR3) (xx) % 21.Didthepatientreceiveastem celre-infusionduetoinadequatehematopoietic function?(reinfuse) 22.Recorddateofinfusion:(INFUSEDT) (mm/dd/yyyy) Comments:(HEMCOMM1)

39 AdditionalSelectionOptionsforHEM Methodofevaluation: 9-9-Other,specify

40 BloodandMarrow TransplantClinical TrialsNetwork Segment(PROTSEG): InfectionSite(INFSITE): InfectionStartDate(INFSTDT): InfectionForm (INF) WebVersion:1.0;4.00; INFECTION I 1.Typeofinfection:(INFTYP01) B-B-Bacteria V-V -Viral F-F-Fungal P-P-Protozoal O-O -Other 2.Organism I:(ORGN01) Ifotherspecify:(INFSPEC1) 3.Recordthelevelofcertaintyofthefungalinfectiondiagnosis:(CERTNTY1) 4.Severityofinfection:(SVRTY01) B01-B01-Acinetobacter(baumani,calcoaceticus,lwofi,otherspecies) B02-B02-Agrobacterium radiobacter B03-B03-Alcaligenesxylosoxidans B04-B04-Anaerobicbacteria(NOS,exceptforBacteroides,Clostridium) B05-B05-Bacilus(cereus,otherspecies) 1-1-ProvenFungalInfection 2-2-ProbableFungalInfection 3-3-PossibleFungalInfection 1-1-Moderate 2-2-Severe 3-3-Life-Threatening/Fatal? INFECTION I 5.Typeofinfection:(INFTYP02) B-B-Bacteria V-V -Viral F-F-Fungal P-P-Protozoal O-O -Other 6.Organism I:(ORGN02) Ifotherspecify:(INFSPEC2) 7.Recordthelevelofcertaintyofthefungalinfectiondiagnosis:(CERTNTY2) B01-B01-Acinetobacter(baumani,calcoaceticus,lwofi,otherspecies) B02-B02-Agrobacterium radiobacter B03-B03-Alcaligenesxylosoxidans B04-B04-Anaerobicbacteria(NOS,exceptforBacteroides,Clostridium) B05-B05-Bacilus(cereus,otherspecies) 1-1-ProvenFungalInfection 2-2-ProbableFungalInfection 3-3-PossibleFungalInfection 8.Severityofinfection:(SVRTY02) 1-1-Moderate 2-2-Severe 3-3-Life-Threatening/Fatal INFECTION I 9.Typeofinfection:(INFTYP03) B-B-Bacteria V-V -Viral F-F-Fungal P-P-Protozoal O-O -Other

41 10.Organism I:(ORGN03) B01-B01-Acinetobacter(baumani,calcoaceticus,lwofi,otherspecies) B02-B02-Agrobacterium radiobacter B03-B03-Alcaligenesxylosoxidans B04-B04-Anaerobicbacteria(NOS,exceptforBacteroides,Clostridium) B05-B05-Bacilus(cereus,otherspecies) Ifotherspecify:(INFSPEC3) 11.Recordthelevelofcertaintyofthefungalinfectiondiagnosis:(CERTNTY3) 1-1-ProvenFungalInfection 2-2-ProbableFungalInfection 3-3-PossibleFungalInfection 12.Severityofinfection:(SVRTY03) 1-1-Moderate 2-2-Severe 3-3-Life-Threatening/Fatal 13.Wasanagent(s)administeredtotreattheinfection(s)?(TRTINF) Provideagent(s)administeredforthisinfectiousperiod: st agent:(agent1) abacavir-abacavir(ziagen) acyclovir-acyclovir(zovirax) albendazole-albendazole(albenza) amantadine-amantadine(symmetrel,symadine) amikacin-amikacin(amikin) Ifotherspecify:(AGTSPEC1) nd agent:(agent2) abacavir-abacavir(ziagen) acyclovir-acyclovir(zovirax) albendazole-albendazole(albenza) amantadine-amantadine(symmetrel,symadine) amikacin-amikacin(amikin) Ifotherspecify:(AGTSPEC2) rd agent:(agent3) abacavir-abacavir(ziagen) acyclovir-acyclovir(zovirax) albendazole-albendazole(albenza) amantadine-amantadine(symmetrel,symadine) amikacin-amikacin(amikin) Ifotherspecify:(AGTSPEC3) 17.Wereadditionalagentsadministeredforthisinfectiousperiod?(ADDAGENT) Ifyes,specifyadditionalagentsadministered:(INFSPEC4) Comments:(INFCOM)

42 AdditionalSelectionOptionsforINF InfectionSite(INFSITE)(keyfield): Blood/BufyCoat Disseminated-Generalized,Isolatedat2orMoreDistinctSites Brain SpinalCord MeningesandCSF CentralNervousSystem Unspecified Lips Tongue,OralCavity,andOro-Pharynx Esophagus Stomach GalbladderandBiliaryTree(NotHepatitis),Pancreas SmalIntestine LargeIntestine Feces/Stool Peritoneum Liver GastrointestinalTractUnspecified UpperAirwayandNasopharynx Larynx LowerRespiratoryTract(Lung) PleuralCavity,PleuralFluid Sinuses RespiratoryTractUnspecified Kidneys,RenalPelvis,UretersandBladder Prostate Testes FalopianTubes,Uterus,Cervix Vagina Genito-UrinaryTractUnspecified GenitalArea Rash,Pustules,orAbscessesNotTypicalofAnyoftheAbove SkinUnspecified Woundsite CatheterTip Eyes Ears Joints BoneMarow BoneCortex(Osteomyelitis) Muscle(ExcludingCardiac) Cardiac(Endocardium,Myocardium,Pericardium) LymphNodes Spleen OtherUnspecified Organism I: B06-B06-Bacteroides(gracilis,uniformis,vulgaris,otherspecies) B07-B07-Borrelia(Lymedisease) B08-B08-BranhameliaorMoraxelacatarhalis(otherspecies) B09-B09-Campylobacter(alspecies) B11-B11-Chlamydia B12-B12-Citrobacter(freundi,otherspecies) B13-B13-Clostridium (alspeciesexceptdificile) B14-B14-Clostridium dificile B15-B15-Corynebacterium (alnon-diptheriaspecies) B16-B16-Coxiela B17-B17-Enterobacter B18-B18-Enterococcus(alspecies) B19-B19-Escherichia(alsoE.coli) B20-B20-Flavimonasoryzihabitans B21-B21-Flavobacterium B22-B22-Fusobacterium nucleatum B23-B23-Gram NegativeDiplococci(NOS) B24-B24-Gram NegativeRod(NOS) B25-B25-Gram PositiveCocci(NOS) B26-B26-Gram PositiveRod(NOS) B27-B27-Haemophilus(alspeciesincludinginfluenzae) B28-B28-Helicobacterpylori B29-B29-Klebsiela B30-B30-Lactobacilus(bulgaricus,acidophilus,otherspecies) B31-B31-Legionela B32-B32-Leptospira B33-B33-Leptotrichiabuccalis B34-B34-Leuconostoc(alspecies) B35-B35-Listeria B36-B36-Methylobacterium B37-B37-Micrococcus(NOS) B38-B38-Mycobacteria(avium,bovium,haemophilum,intercelulare) B39-B39-Mycoplasma B40-B40-Neisseria(gonorhoea,meningitidis,otherspecies) B41-B41-Nocardia B42-B42-Pharyngeal/RespiratoryFlora B43-B43-Propionibacterium (acnes,avidum,

43 granulosum,otherspecies) B44-B44-Pseudomonas(alspeciesexcept cepaciaandmaltophilia) B45-B45-PseudomonasorBurkholderiacepacia B46-B46-PseudomonasorStenotrophomonasorXanthomonasmaltophilia B47-B47-Rhodococcus B48-B48-Ricketsia B49-B49-Salmonela(alspecies) B50-B50-Serratiamarcescens B51-B51-Shigela B52-B52-Staphylococcus(coag-) B53-B53-Staphylococcus(coag+) B54-B54-Staphylococcus(NOS) B55-B55-Stomatococcusmucilaginosis B56-B56-Streptococcus(alspeciesexceptEnterococcus) B57-B57-Treponema(syphilis) B58-B58-Tuberculosis(NOS,AFB,acidfastbacilus,Kochbacilus) B59-B59-TypicalTuberculosis(TB,Tuberculosis) B60-B60-Vibrio(alspecies) B99-B99-OtherBacteria V01-V01-HerpesSimplex(HSV1,HSV2) V02-V02-HerpesZoster(Chickenpox,Varicela) V03-V03-Cytomegalovirus(CMV) V04-V04-Adenovirus V05-V05-Enterovirus(Coxsackie,Echo,Polio) V06-V06-HepatitisA(HAV) V07-V07-HepatitisB(HBV,Australianantigen) V08-V08-HepatitisC (includesnon-aandnon-b,hcv) V09-V09-HIV-1,HITLV-I V10-V10-Influenza(Flu) V11-V11-Measles(Rubeola) V12-V12-Mumps V13-V13-Papovavirus V14-V14-RespiratorySyncytialvirus(RSV) V15-V15-Rubela(GermanMeasles) V16-V16-Parainfluenza V17-V17-HHV-6(HumanHerpesVirus) V18-V18-Epstein-BarVirus(EBV) V19-V19-Polyomavirus V20-V20-Rotavirus V21-V21-Rhinovirus(CommonCold) V22-V22-OtherViral P01-P1-Pneumoncystis(PCP) P02-P2-Toxoplasma P03-P3-Giardia P04-P4-Cryptosporidium P05-P5-Amebiasis P06-P6-Echinocoocalcyst P07-P7-Trichomonas(eithervaginalorgingivitis) P08-P8-OtherProtozoal(Parasite) O01-O1-Mycobacterium Tuberculosis O02-O2-OtherMycobacterium O03-O3-Mycoplasma O04-O4-OtherOrganism F01-F01-CandidaAlbicans F02-F02-CandidaKrusei F03-F03-CandidaParasilosis F04-F04-CandidaTropicalis F05-F05-TorulopsisGalbrata(asubspeciesofCandida) F06-F06-Candida(NOS) F07-F07-AsperguilusFlavus F08-F08-AsperguilusFumigatus F09-F09-AsperguilusNiger F10-F10-Asperguilus(NOS) F11-F11-CryptococcusSpecies F12-F12-Fusarium Species F13-F13-Mucormycosis(Zygomycetes,Rhizopus) F14-F14-Yeast(NOS) F15-F15-OtherFungus 1 st agent: amoxicilin/clavulanate-amoxicilin/clavulanate(augmentin) amphotericinb-amphotericinb(abelcet,amphotec,fungizone) ampicilin-ampicilin(omnipen,polycilin) ampicilin/sulbactam-ampicilin/sulbactam (Unasyn) amprenavir-amprenavir(agenerase) atovaquone-atovaquone(meprone) azithromycin-azithromycin(zithromax,z-pack) cefaclor-cefaclor(ceclor) cefadroxil-cefadroxil(duricef,ultracef) cefazolin-cefazolin(ancef,kefzol) cefdinir-cefdinir(omnicef) cefepime-cefepime(maxipime) cefixime-cefixime(suprax) cefoperazone-cefoperazone(cefobid) cefotaxime-cefotaxime(claforan) cefotetan-cefotetan(cefotan)

44 cefoxitin-cefoxitin(mefoxin) cefpodoxime-cefpodoxime(vantin) cefprozil-cefprozil(cefzil) ceftazidime-ceftazidime(fortaz,tazicef) ceftriaxone-ceftriaxone(rocephin) cefuroxime-cefuroxime(ceftin,kefurox,zinacef) cephalexin-cephalexin(keflet,keflex,keftab) chloramphenicol-chloramphenicol(chloromycetin) cidofovir-cidofovir(vistide) ciprofloxacin-ciprofloxacin(cipro) clarithromycin-clarithromycin(biaxin) clindamycin-clindamycin(cleocin) clotrimazole-clotrimazole(mycelex,lotrimin) clotrimoxazole/betamethasone-clotrimoxazole/betamethasone(lotrisone) co-trimoxazole-co-trimoxazole(bactrim,septra,sulfamethoprim) dapsone-dapsone(dds) dicloxacilin-dicloxacilin(dycil,dynapen,pathocil) didanosine-didanosine(videx,ddi) doxycycline-doxycycline(vibramycin) efavirenz-efavirenz(sustiva) erythromycin-erythromycin(ery-tab,ilosone,pediamycin) erythromycin/sulfisoxazole-erythromycinethyl/sulfisoxazole(pediazole) erythromycintopical-erythromycintopical(akne-mycin,eryderm) ethambutol-ethambutol(myambutol) famciclovir-famciclovir(famvir) fluconazole-fluconazole(diflucan) flucytosine-flucytosine(ancobon) foscarnet-foscarnet(foscavir) ganciclovir-ganciclovir(cytovene) gatifloxacin-gatifloxacin(tequin) gentamicin-gentamicin(garamycin,gentacidin) grepafloxacin-grepafloxacin(raxar) hepatitisavaccine-hepatitisavaccine(havrix,vaqta) hepatitisbvaccine-hepatitisbvaccine(recombivaxhb,engerix-b) hepatitiscvaccine-hepatitiscvaccine imipenem /cilastatin-imipenem /cilastatin(primaxin) imiquimod-imiquimod(aldara) indinavir-indinavir(crixivan) interferonalfacon-1-interferonalfacon-1(infergen) interferonbeta-1a-interferonbeta-1a(avonex) interferonbeta-1b-interferonbeta-1b(betaseron) isoniazid-isoniazid(inh,lanizid,nydrazid) itraconazole-itraconazole(sporonox) ivermectin-ivermectin(stromectol) kanamycin-kanamycin(kantrex) ketoconazole-ketoconazole(nizoral) lamivudine-lamivudine(epivir,3tc) levofloxacin-levofloxacin(levaquin) linezolid-linezolid(zyvox) lopinavir/ritonavir-lopinavir/ritonavir(kaletra) mefloquine-mefloquine(larium) meropenem-meropenem (Merem I.V.) metronidazole-metronidazole(flagyl,protostat) minocycline-minocycline(arestin) moxifloxacinhydrochloride-moxifloxacinhydrochloride(avelox) mupirocin-mupirocin(bactroban) nafcilin-nafcilin(nalpen,unipen) nelfinavir-nelfinavir(viracept) neomycin-neomycin(mycifradin,myciguent) neomycin/polymxin/hydrocortisone-neomycin/polymxin/hydrocortisone(cortisporin) nevirapine-nevirapine(viramune) nitrofurantoin-nitrofurantoin(macrobid) nystatin-nystatin(mycostatin) oseltamivir-oseltamivir(tamiflu) oxacilin-oxacilin(bactocil) palivizumab-palivizumab(synagis) peniciling-peniciling(bicilin) penicilinvk-penicilinvk(v-cilink,veetids) pentamidine-pentamidine(pentam 300) piperacilin-piperacilin(pipracil) piperacilin/tazobactam-piperacilin/tazobactam (Zosyn) podofilox-podofilox(condylox) polymyxin-polymyxin(ak-sporeh.c.,cortisporinophthalmicsuspension) ppd-ppd skintest(mantouxtest,tinetest) pyrazinamide-pyrazinamide(rifater) pyrimethamine-pyrimethamine(daraprim) quinidinegluconate-quinidinegluconate(duraquin,cardioqiuin) quinupristin/dalfopristin-quinupristin/dalfopristin(synercid) respiratorysyncytialimmuneglobulin-respiratorysyncytialimmuneglobulin(respigam) ribavirin-ribavirin(virazole) rifampin-rifampin(rifadin,rimactane) rifampin/isoniazid-rifampin/isoniazid(rifamate,rimactane/inh) rifampin/isoniazid/pyrazinamide-rifampin/isoniazid/pyrazinamide(rifater) rimantadine-rimantadine(flumadine) ritonavir-ritonavir(norvir) saquinavirmesylate-saquinavirmesylate(fortovase,invirase) stavudine-stavudine(d4t,zerit)