Form Approved
O
MB
No. 0920-0666
Exp. Date: 01/31/25
www.cdc.gov/nhsn
Hemovigilance Module
Monthly Reporting Denominators
*Required for saving
*Facility ID#: ____________________ |
*Month: ______________ |
*Year: ____________ |
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Table 1 |
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Products |
*Units Transfused |
*Aliquots Transfused |
*Total Discards |
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Whole Blood |
TOTAL |
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Red blood cells |
Whole blood derived |
TOTAL |
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Not irradiated or leukocyte reduced |
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Irradiated |
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Leukocyte reduced |
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Irradiated and leukocyte reduced |
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Apheresis |
TOTAL |
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Not irradiated or leukocyte reduced |
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Irradiated |
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Leukocyte reduced |
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Irradiated and leukocyte reduced |
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Platelets |
Whole blood derived |
TOTAL |
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Not irradiated or leukocyte reduced |
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Irradiated |
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Leukocyte reduced |
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Irradiated and leukocyte reduced |
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Apheresis |
TOTAL |
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Not irradiated or leukocyte reduced |
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Irradiated |
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Leukocyte reduced |
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Irradiated and leukocyte reduced |
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Plasma (all types) |
Total whole blood derived |
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Total apheresis |
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Cryoprecipitate |
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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 79 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 |
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^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
*Patient samples collected for type and screen or crossmatch: __________ |
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*Total crossmatch procedures: __________ |
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Total patients transfused: __________ |
Hemovigilance Module
Monthly Reporting Denominators
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CDC 57.303 Rev. 5, v8.8
Page
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.303 |
Subject | NHSN OMB Forms 2020 |
Author | CDC/NCZEID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-11-19 |