Notification Of Donor Clearance Template
Download a blank fillable Notification Of Donor Clearance Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Notification Of Donor Clearance Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2NOTIFICATION OF DONOR CLEARANCE
F80
Page 1 of 2
HPC, Marrow
HPC, Apheresis
MNC, Apheresis
If final clearance for donation is NOT granted, please complete form C30 instead.
SECTION A: TO BE COMPLETED BY THE APHERESIS/COLLECTION CENTRE
PATIENT DATA
Patient name:
Patient registry:
Date of birth: (YYYY-MM-DD)
Patient ID:
Patient ID:
(assigned by patient registry)
(assigned by donor registry)
DONOR DATA
Donor registry:
Donor ID:
Date of birth:
Gender:
Weight:(kg)
CMV:
Blood group/RhD:
(YYYY-MM-DD)
Transfusions:
Number/year:
Pregnancies:
Number:
Irregular antibodies:
COLLECTION DATE INFORMATION
Donor informed consent signed on: (YYYY-MM-DD)
Donor clearance confirmed on: (YYYY-MM-DD)
First date of donor G-CSF injections: (YYYY-MM-DD)
Confirmed first collection date: (YYYY-MM-DD)
TEST DATA
Date of blood collection:
Donor Infectious Disease Test Results
Positive
Negative
Not tested
(YYYY-MM-DD)
HBsAg (Hepatitis B surface antigen screening test)
Anti-HBc (Hepatitis B core antibody)
If positive: Anti HBs titer
I U/ml; HBV-PCR
Anti-HCV (Hepatitis C antibody screening test)
HCV-PCR (PCR Hepatitis C virus test)
Anti-HIV 1/2 (antibodies to HIV 1/2 screening test)
HIV 1-PCR (PCR HIV test)
STS (serologic test for syphilis
Anti-HTLV I / II (antibodies to human
T-lymphotropic virus I / II screening test)
CMV (Cytomegalovirus) antibodies IgG
IgM
EBV (Epstein Barr Virus) antibodies IgG
IgM
Toxoplasmosis antibodies
IgG
IgM
Other tests (please specify):
20160701-WGRE-FORM-F80
Reset Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal