Declaration of consent November 2010 1

Universitätsklinikum Leipzig AöR, Institut für Transfusionsmedizin

Datei freiwilliger unverwandter Knochenmark- und Stammzellspender Leipzig Spendennummer
Delitzscher Strasse 135 , 04129 Leipzig Blood sample number
HLA –Labor, Tel.: 0341-97 25 314, Fax: 0341-97 25 359,
E-Mail: info@blutbank-leipzig.de Homepage: www.blutbank-leipzig.de

Revocable declaration of consent to marrow and blood stem cell

donation

After receipt and attentive reading of the information sheet I declare myself ready to donate voluntarily
marrow or blood stem cells free of charge for an unrelated recipient patient. I’m agree, that 10 ml blood
is taken from me for serological or molecular-biological determination of my tissue markers (HLA-
markers), including isolation and storage of DNA-substance for a later testing of tissue typing. I was
informed about the purpose of the HLA classification. I did have the opportunity to to place questions.
I have understood that I may withdraw my consent for the marrow/blood stem cell donation at any time
without the need to give reasons.

My declaration of consent includes the consent to the storage of my personal data and my tissue
markers according to the valid data protection regulations. I agree to the transfer of those of my data
(tissue markers, size, weight, sex and date of birth in anonymous form: donor number only) that are
important for transplantation purposes to the center for marrow donor registry for Germany (ZKRD) in
Ulm and to the exchange of the data with international donor registries.

I was advised about the possibility of health risks (e.g. risks of narcosis and treatment with growth
factors before a blood stem cell sampling). In order to minimize these risks and side effects I agree to
further medical investigations for the event of a blood stem cell sampling. If I should become a donor, I
agree to an investigation of my blood infection markers and gone through infections for the protection of
the recipient patient. I will communicate a possible change of residence to the Institut for
Transfusionsmedizin and if not, I agree to an inquiry to my residents' registration office.

Please fill out in block letters:

Family name: _____________________________ First name: _____________________________

Blood group: _____________________________ Date of Birth: __ __ I __ __ I __ __ __ __

(if known)
Donor number: _____________________________
sex: O O (if known)
male female

Adress in Germany:

Street and House Number:_________________________________________________________________

Postal Code: ________________ City: ____________________________________________________

Private phone number: _____________________ phone number at work: __________________________

Fax:_________________________________ E-Mail: _______________________________________

City, Date: ______________________________ Signature: _____________________________________

 Declaration of consent November 2010 2

Adress in your home country:

Street and House Number:_________________________________________________________________

Postal Code: ________________ City:____________________________________________________

Private phone number: _____________________ phone number at work: _________________________

Fax:_________________________________ E-Mail: _______________________________________

City, Date: ______________________________ Signature: ____________________________________

I was informed about the meaning and risks of marrow and blood stem cell donation by the signing
physician. My questions were answered in understandable manner.

.............................................................
Signing physician
Exclusion criteria for a registration

As a donor you must be in principle healthy. Please inform us also about heavy and/or longer lasting
illnesses additionally to those specified below; it has to be decided in every individual case whether this
illness can mean an endangerment for the donor or receiver.

A.1. Reasons, which generally exclude a stem cell donation

 cancer and other malicious new formations (also healed)
 Insulin-requiring diabetes mellitus
 Creutzfeldt Jakob illness as well as transplantation of Dura Mater (hard brain skin) or cornea
(cornea/callosity)
 Creutzfeldt Jakob anamnesis in the family
 treatment with hypophysis hormones of human origin e.g. growth hormones
 serious therapy-requiring asthma bronchiale
 heavy chronic obstructive bronchitis (COPD)
 heavy heart illnesses like coronar heart illness, angina pectoris, heavy arrrhythmia, cardiac infarct
 heavy kidney illnesses
 illnesses of the blood vessel system like cerebrovascular illnesses, arterial thromboses, recurring
venous thromboses
 continuous excretion of salmonellae (typhoid fever and paratyphoid fever pathogenic agents)
 acute and chronic hepatitis (infectious jaundice)
 HIV infection (AIDS)
 not fully healed sexual diseases such as syphilis or gonorrhea
 autoimmune illnesses such as disease Crohn, disease Basedow, rheumatoid arthritis, multiple
sclerosis, Lupus of erythematodes, colitis
 osteomyelitis (marrow inflammation)
 addiction illnesses such as medicine, drug or alcohol addiction
 heterosexual persons with sexual risk behavior, e.g. sexual intercourse with frequently changing
partners
 men who have intercourse with men
 male and female prostitutes
 miasis (chagas or sleep illness), Leishmaniasis, malaria, leprosy, Brucellosis, Rickettsiosis, relapse
fever, Tularemia (hare plague)
 Hereditary blood diseases like e.g. Thalassemia, sickle cell anemia
 Transplant with a fabric or an organ of animal origin..
 Declaration of consent November 2010 3

A.2. Reasons which exclude a stem cell donation temporarily or require a postponement

In cases which require a longer postponement, a blocking of the donor is necessary until the cause is no
longer present. In cases, which require only a short postponement, the donor may be temporarily blocked.

 epilepsies (unless at least 3 years accumulation-free without treatment)

 heavy kidney illnesses (e.g. acute glomerulonephritis), 5 years
 rheumatic fever, 2 years (if no chronic heart illness the consequence was, otherwise continuing
exclusion)
 tuberculosis, after healing completely for 2 years
 pregnancy/abortion, 6 months after birth, and/or up to the end of lactation
 operations, usually 4 months
 endoscopy/biopsy with flexible instruments, 4 months
 transfusions of foreign blood, plasma derivatives or other blood preparations, 4 months
 prisoners during the detention and after release from custody 4 months

A.3. Illnesses that require individual clearance

 allergies
 bronchitis
 high blood pressure