Form 57.303 Hemovigilance Module Monthly Reporting Denominators

OMB No. 0920-0666

Exp. Date: xx-xx-20xx

Hemovigilance Module

Monthly Reporting Denominators

Facility ID # __________________ Month: ___ ___ Year: ___ ___ ___ ___

* Indicates required fields

*Product		*Units Transfused
Platelets: apheresis	Total apheresis platelets
	Number irradiated
	Number leukocyte reduced
	Number irradiated & leukocyte reduced
Platelets: whole blood derived	Total whole blood derived platelets
	Number irradiated
	Number leukocyte reduced
	Number irradiated & leukocyte reduced
Red blood cells	Total red blood cells
	Number irradiated
	Number leukocyte reduced
	Number irradiated & leukocyte reduced
Aliquots of RBCs
Plasma (all types)
Cryoprecipitate

*Total samples collected: _______________

*Total number of red blood cell units from which aliquots were made: ____________

Custom Fields

Label ________ ________ ________ ________ ________

Data ________ ________ ________ ________ ________

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).

CDC 57.303