Part A Rapid notification format for suspected serious adverse reactions

Reporting establishment

Report identification

Reporting date (year/month/day)

Date of transfusion (year/month/day)

Age and sex of recipient

Date of serious adverse reaction (year/month/day)

Serious adverse reaction is related to

• Whole blood

• Red blood cells

• Platelets

• Plasma

• Other (specify)

Type of serious adverse reaction(s)

• Immunological haemolysis due to ABO incompatibility

• Immunological haemolysis due to other allo-antibody

• Non-immunological haemolysis

• Transfusion-transmitted bacterial infection

• Anaphylaxis/hypersensitivity

• Transfusion related acute lung injury

• Transfusion-transmitted viral infection (HBV)

• Transfusion-transmitted viral infection (HCV)

• Transfusion-transmitted viral infection (HIV-1/2)

• Transfusion-transmitted viral infection, Other (specify)

• Transfusion-transmitted parasitical infection (Malaria)

• Transfusion-transmitted parasitical infection, Other (specify)

• Post-transfusion purpura

• Graft versus host disease

• Other serious reaction(s) (specify)

Imputability level (NA, 0-3)