Donor's Name: _________________________ Donor #: _________________
Age: ______________ Number of previous donations: ___________________
Previously implicated? ___ Yes ___ No
If yes, patient's name: ____________________ Hospital #: _______________
Date of transfusion: _______________________________________________
Results of donor's HBsAg test: Pos. __ Neg. __ Date _____ Method ________
Donor removed from active list: _______ 6 mos. ______Permanently
Letter of notification sent: ___ Yes ___ No _______________ Date
Hepatitis patient (current recipient): ___________________________________
Hospital number.
______________________________________________________
Duration of follow-up post-transfusion - Remarks: ________________________
________________________________________________________________
Review last four recipients within past 2 years of the above implicated donor of
blood or blood components
Record of Follow-up Viral Hepatitis after Transfusion
____Donation___Donor___Recipient Name_&_No.___Yes___No___Yes___No
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Figure 3-7. Hepatitis implicated donor form.
MD0846
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