Form 57.303 Hemovigilance Module Monthly Reporting Denominators

OMB No. 0920-0666

Exp. Date: XX-XX-XXXX

Hemovigilance Module

Monthly Reporting Denominators

*Required for saving

*Facility ID#: ____________________				*Month: ______________				*Year: ____________
Product						*Units Transfused			*Aliquots Transfused
Red blood cells	Whole blood derived		TOTAL
			Irradiated
			Leukocyte reduced
			Irradiated and leukocyte reduced
	Apheresis		TOTAL
			Irradiated
			Leukocyte reduced
			Irradiated and leukocyte reduced
Platelets	Whole blood derived		TOTAL
			Irradiated
			Leukocyte reduced
			Irradiated and leukocyte reduced
	Apheresis		TOTAL
			Irradiated
			Leukocyte reduced
			Irradiated and leukocyte reduced
Plasma (all types)	Total whole blood derived
	Total apheresis
Cryoprecipitate
*Total samples collected: __________
Custom Fields
Label					Label
________________		___________________			________________		___________________
________________		___________________			________________		___________________
Assurance of Confidentiality: The voluntarily provided 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 Rev. 1, v6.4

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