Form CDC 57.303 CDC 57.303 Hemovigilance Module Monthly Reporting Denominators

[NCEZID] The National Healthcare Safety Network (NHSN)

57.303_HV Monthly Reporting Denoms_BLANK_0607

57.303 Hemovigilance Module Monthly Reporting Denominators

OMB: 0920-0666

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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: ____________

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 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

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




Pathogen Reduction Cryoprecipitated Fibrinogen Complex




^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


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CDC 57.303 Rev. 5, v8.8

Page 3 of 7

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.303
SubjectNHSN OMB Forms 2020
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-09-05

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