Relapsed or Refractory CD30-Positive Lymphomas

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* 1. Please complete the following questionnaire in case you match a study!

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Have you been diagnosed with Hodgkin Lymphoma, Aggressive Non- Hodgkin Lymphoma, Negative Anaplastic T cell Lymphoma or positive anaplastic T cell lymphoma?

Yes

No

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* 3. Is your current age between 12-75 years old?

Yes

No

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* 4. Is your bilirubin less than 2 times normal (3 times if you have Gilberts)?

Yes

No

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* 5. Is your AST less than 3x the normal amount?

Yes

No

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* 6. Is your kidney function normal or GFR greater then 70 mL/min?

Yes

No

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* 7. Is your pulse oximetry greater then 90% on room air?

Yes

No

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* 8. Does your EKG show a normal heart rhythm?

Yes

No

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* 9. Are you free from any toxic affects from prior chemo?

Yes

No

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* 10. If childbearing, are you on effective birth control?

Yes

No

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* 11. Are you free of cardiac symptoms?

Yes

No

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* 12. Are you free of active viral, bacterial and fungal infections?

Yes

No

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* 13. If you are on corticosteroids, is your current dose less then 10mg/day?

Yes

No

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* 14. Are you free of tumors that could cause airway obstruction?

Yes

No