Form CDC 57.303 CDC 57.303 Hemovigilance Module Monthly Reporting Denominators

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Hemovigilance Module

Monthly Reporting Denominators

*Required for saving

*Facility ID#: ____________________			*Month: ______________			*Year: ____________
Table 1
Products				*Units Transfused	*Aliquots Transfused		*Total Discards
Whole Blood		TOTAL
Red blood cells	Whole blood derived	TOTAL
		Not irradiated or leukocyte reduced
		Irradiated
		Leukocyte reduced
		Irradiated and leukocyte reduced
	Apheresis	TOTAL
		Not irradiated or leukocyte reduced
		Irradiated
		Leukocyte reduced
		Irradiated and leukocyte reduced
Platelets	Whole blood derived	TOTAL
		Not irradiated or leukocyte reduced
		Irradiated
		Leukocyte reduced
		Irradiated and leukocyte reduced
	Apheresis	TOTAL
		Not irradiated or leukocyte reduced
		Irradiated
		Leukocyte reduced
		Irradiated and leukocyte reduced
Plasma (all types)	Total whole blood derived
	Total apheresis
Cryoprecipitate
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 70 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).

Hemovigilance Module

Monthly Reporting Denominators

*Does your facility transfuse blood products treated with pathogen reduction technology? _____ Yes _______ No

^If yes, then complete Table 2.

Table 2

Products			Units Transfused	Aliquots Transfused	Total Discards
Red blood cells	Whole blood derived	TOTAL
		S-303-treated
		Riboflavin-treated
	Apheresis	TOTAL
		S-303 -treated
		Riboflavin-treated
Platelets	Whole blood derived	TOTAL
		Psoralen-treated
		Riboflavin-treated
	Apheresis	TOTAL
		Psoralen-treated
		Riboflavin-treated
Plasma (all types)	Whole blood derived	TOTAL
		Psoralen-treated
		Riboflavin-treated
	Apheresis	TOTAL
		Psoralen-treated
		Riboflavin-treated
Cryoprecipitate		TOTAL
		Psoralen-treated
		Riboflavin-treated

^If your facility transfused pathogen reduced apheresis platelets (e.g., the apheresis platelet total in table 2 is greater than 0), then complete Table 3.

Table 3

Products			Units Transfused	Aliquots Transfused	Total Discards
Platelets	Apheresis	Psoralen-treated
		Psoralen-treated and in Plasma
		Psoralen-treated and in Platelet additive solution
		Riboflavin-treated
		Riboflavin-treated and in Plasma
		Riboflavin-treated and in Platelet additive solution

*Patient samples collected for type and screen or crossmatch: __________

*Total crossmatch procedures: __________

Total patients transfused: __________

Hemovigilance Module

Monthly Reporting Denominators

Custom Fields
Label		Label
________________	___________________	________________	___________________
________________	___________________	________________	___________________
________________	___________________	________________	___________________
________________	___________________	________________	___________________

CDC 57.303 Rev. 4, v8.5.3

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