ࡱ> gif bjbjVV @<<a 1 ;!;!;!$_!_!_!P!<!T_!xS?"?""""%%%SSSSSSSvUXS;!'$$"''S ""2S,,,'X 8";!"S,'S,,nL#!qO"pd_!'XM SHS0xS NdX;(X@qOqO&X;!Op%hm%J,%<%%%%SS+%%%xS''''X%%%%%%%%% : What this form is about This form is used to document approvals for disposal of HPC, Apheresis products. Who should use this form This form applies to HPC, Apheresis processing staff who obtain approvals from the American Red Cross medical director and the transplant physician for disposal of HPC, Apheresis products. Instructions Record patients name Record patients identification number Record reason for disposal Record HPC UDI numbers for products requiring disposal Record transplant physicians signature and the date Print transplant physicians name ARC USE ONLY Section Record medical directors signature and the date for disposal approval Print medical directors name Record the patient name, patient ID#, and method of disposal Record complete product identification number of the products to be disposed. Two techs will verify that the proper products are selected and disposed and each will record initials and date to document the disposal. Reviewer records initial and date to document review of the completed form Revision HistoryRevision NumberSummary of Revisions1.0Initial Version [Document converted from 07.05.PPL.00.00(FRM1) HPC Disposal Authorization] ### I authorize disposal of the following HPC, Apheresis products collected from the patient listed. Patient Name ______________________________ ID# _________________________ Reason for Disposal: ___________________________________________________________ HPC, Apheresis _______________ _______________ _______________ Products to Dispose _______________ _______________ _______________ _____________________________________________ ______________________ Transplant Physician Signature Date _____________________________________________ Print Transplant Physician Name ARC USE ONLY ARC Medical Director Approval of Disposal _________________________________________ _________________ ARC Medical Director Signature Date _________________________________________ Print ARC Medical Director Name Patient Name: ____________________________________ ID# ________________________________________ Method of Disposal: _____________________________________ HPC, Apheresis Product(s) Disposed: Disposal Tech Verify tech (initials/date) (initials/date) ____________________________________ _____________ ______________ ____________________________________ _____________ ______________ ____________________________________ _____________ ______________ ____________________________________ _____________ ______________ Reviewed By / Date: ______________________________     American Red Cross Biomedical Services Page  PAGE 2 of  SECTIONPAGES 2 Form: HPC, Apheresis Disposal Authorization 16.4.Zfrm031 W2029 v1.0 American Red Cross Biomedical ServicesDoc No 16.4.Zfrm031 W2029Version 1.0Form: HPC, Apheresis Disposal Authorization  American Red Cross Biomedical Services Instructions - Page  PAGE 1 of  SECTIONPAGES 1 Form: HPC, Apheresis Disposal Authorization 16.4.Zfrm031 W2029 v1.0 American Red Cross Biomedical Services Page  PAGE 2 of  SECTIONPAGES 2 Form: HPC, Apheresis Disposal Authorization 16.4.Zfrm031 W2029 v1.0 American Red Cross Washington, DC 20006HPC, Apheresis Disposal Authorization American Red Cross Biomedical Services Page  PAGE 1 of 1 Form: HPC, Apheresis Disposal Authorization 16.4.Zfrm031 W2029 v1.0  EMju~@ L M U W X [ ] c d 4 5 J        $ & L _ y 鷳h{/^JaJ h{/^Jh \ShXv^Jh$Z^hXv5^JhXv h \ShXvhP hlhw@CJOJQJaJhV hlhw@CJOJQJaJhPhWhR hlhwhM{bhwh<h{%5j@ M d  4 5 J <   gdw & F gd8 & F gdRgd8 0*$gdB & F gd8 gdBgdBgd<   % & 6 K $$Ifa$gdXv;kd$$Ifl$$$64 lal $IfgdXv & F8^8`gdPK L P |o xx$IfgdXv$xx$Ifa$gdXvskd[$$Ifl0$ 0$64 lal   q r xxxxxxxxx 0*$gd<'gd%U'gddEskd $$Ifl0$ 0$64 lal    # 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