Recipient Complications - Infectious Disease Case Report FOR RED CROSS USE ONLY Case ID number: Surveillance event number: Section II: Transfusion History Total number of Red Cross products you are reporting: ______(If the total number of products exceeds the lines available, use additional copies of this page to record). Red Cross-Supplied Blood Products For Transfusion Service Use For Red Cross Use Only Unit number Product name or Transfusion date Unit Collection Date last tested Retest date Follow-up test Cleared code involved* date (or N/A) (or NA or LTF) results No R No N/A Yes NR Yes No R No N/A Yes NR Yes No R No N/A Yes NR Yes No R No N/A Yes NR Yes No R No N/A Yes NR Yes No R No N/A Yes NR Yes No R No N/A Yes NR Yes No R No N/A Yes NR Yes *Unit involvement recorded by: ________________________________________ (Identity/date—Case investigator can initial at medical director’s direction.)
Recipient Complications - Infectious Disease Case Report FOR RED CROSS USE ONLY Case ID number: Surveillance event number: Section II: Transfusion History Total number of Red Cross products you are reporting: ______(If the total number of products exceeds the lines available, use additional copies of this page to record). Red Cross-Supplied Blood Products For Transfusion Service Use For Red Cross Use Only Unit number Product name or code Transfusion date Unit involved* Collection date Date last tested (or N/A) Retest date (or NA or LTF) Follow-up test results Cleared No Yes R NR No Yes N/A No Yes R NR No Yes N/A No Yes R NR No Yes N/A No Yes R NR No Yes N/A No Yes R NR No Yes N/A No Yes R NR No Yes N/A No Yes R NR No Yes N/A No Yes R NR No Yes N/A *Unit involvement recorded by: ________________________________________ (Identity/date—Case investigator can initial at medical director’s direction.)
3403_11.4.frm600_-_arc-doc-008932_v1.5_recipient_complications_-_infectious_disease_case_report_pre-filled.docx