(b) Social security number (include the number which may have been used
at the time of the transfusion).
(c) Sex.
(d) Date of birth.
(e) Current military status.
(f) Current address and phone number, work and home, to include area
code.
(g) The sponsor's name and SSN at the time of transfusion, if applicable.
(h) Names of hospitals for each transfusion (to include if they are military or
a civilian hospitals), and the city and state where each is located.
(i) Dates or time for each transfusion or hospitalization.
(j) Date of recipient's first positive HIV test.
(k) Date(s) of all recipient's negative HIV tests.
(l) Signed and witnessed authorization for release of information which will
be used to obtain further recipient related information required for completion of the
look-back. Minimum information on release form must include the name and address of
the MTF, the recipient's signature and date, and the witness' signature and date. The
medical personnel conducting the interview may witness the release form.
b. Initiation of a Look-Back.
(1) HIV positive individuals may be identified through the force screening
program, the blood donor screening process, preventive medicine contact
investigations, separate look-back investigations, or upon clinical examination of signs
and symptoms of AIDS. HIV positive individuals will be questioned concerning their
blood donation and blood transfusion history since 1977.
(2) If HIV positive individuals give a history of blood donation or receiving a
transfusion, all required information should be collected and a look-back process begun.
(3) When provided with the look-back history, the MTF will undertake a search
of donor, transfusion, receipt, and disposition records. It must also provide information
on the components prepared or received and the disposition of each component
(shipped, transfused, further manufactured, and destroyed). For donations in which
components were transfused, the names and social security numbers of the recipients
MD0868
2-8
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