ࡱ> '` bjbj"9"9 zN@S@SIVVVV$***P+DJ+ϔ++X2,2,2,0.0.0.$h4/."0.//4VV2,2,I>111/V82,2,1/112,+ P2l*/^H:Hϔ<љ~0љ"bљf0.0`."1..d0.0.0.44010.0.0.ϔ////d$$VVVVVVI What this form is about This form is used to document the recipients consent for disposal of Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/P) collected for his/her use. Who should use this form This form applies to HCT/P staff at the Puerto Rico Region responsible for storage and disposal of HCT/P. Instructions This form is used whenever HCT/P units are to be disposed and the intended recipient is alive. HCT/P staff will provide this form to the transplant facilities coordinators. Transplant facilities coordinators will be responsible for documenting the form and getting the necessary signatures. Complete heading by filling in: name of the intended recipient for the product to be disposed of name of facility or hospital where recipient was treated name and address of recipients physician at the facility Complete consent by filling the blanks with the corresponding information: name of physician who informed recipient regarding product disposal reason why the products will not be needed Print the patients name and have him/her sign and date on the corresponding spaces. If the patient is a minor, or is unable to give his/her consent, print the parent or legally authorized representatives name and have him/her sign and date the consent. Document his/her relationship with the patient on the space provided. Print the witness name and have him/her sign and date on the spaces provided. The patients physician or designee must sign and date the consent authorizing disposal of the products. Revision HistoryRevision NumberSummary of Revisions1.0Initial Version. Document converted from Patient consent for Product Disposal [07.05.PPL.00.00(FRM2)].1.1Deleted name of former program medical director.### RECIPIENT CONSENT FOR HCT/P DISPOSAL Recipients name: Facility: Recipients physician: (Name and address of physician at hospital) I hereby certify that my physician or son/daughter's physician explained to me that the hematopoietic progenitor cells which were collected are not going to be used due to: I consent for the American Red Cross Blood Services, Puerto Rico Region to either destroy or use my hematopoietic progenitor cells for further research. Other available treatments, if any, were also explained to me by my physician or son/daughters physician. I understand that the destruction process is free of cost. I have had the opportunity to ask questions. However, if any doubts should arise, I can call my treating physician or the Medical Director of the American Red Cross Blood Services, Puerto Rico Region, during regular working hours at (787) 759-8100, ext. 3873. Recipients Printed Name Recipient's Signature Date  _______ _________________________________________________________ __ __ Witness printed name Witness signature Date ________________________________________ ____________________________ Recipients physician/designee signature Date     PAGE  American Red Cross Biomedical Services Instructions - Page  PAGE 2 of 2 Form: xxx xxx v-x.x American Red Cross Biomedical ServicesDoc No 16.4.Zfrm039 W2054Version 1.1Form: Recipient Consent for HCT/P Disposal  American Red Cross Biomedical Services Instructions - Page  PAGE 1 of 1 Form: Recipient Consent for HCT/P Disposal 16.4.Zfrm039 W2054 v-1.1 American Red Cross Biomedical Service Page  PAGE 1 of  SECTIONPAGES 1 Form: Recipient Consent for HCT/P Disposal 16.4.Zfrm039 W2054 v-1.1 Use only in case of a minor, or if patient unable to sign Parent or legally authorized representative printed name Relationship #)*7;\   : C P Q [ b t u ˾˾ۛ{k^^OhohoCJOJQJaJhAk5CJOJQJaJhChAk5CJOJQJaJhY5CJOJQJaJhl85CJOJQJaJ huaJhxKhuaJho5CJOJQJaJhl@5CJOJQJaJh5CJOJQJaJhAkhl@5CJOJQJaJhAkhAk5CJOJQJaJhhohAkhjhuaJC Q GO & F<Eƀsf^gd~^O & F<Eƀsf^gd~^ `gdAk gdAkgdAk gdu u `O & F<<1$Eƀsfgd~^O & F<Eƀsf^gd~^    $ - / : I I J =Sپzvzl_h~^huCJOJQJh$Z^hu5^Jhu h \ShuhIhAkCJaJhhoCJaJhDHwCJOJQJaJhpDCJOJQJaJhohoCJOJQJaJhl8CJOJQJaJhohhNCJOJQJaJhCJOJQJaJhhhNCJOJQJaJhhNCJOJQJaJ  aO & F<<1$Eƀsfogd~^O & F<<1$Eƀsfogd~^ L XO & F<<1$Eƀsfgd~^X & F Y<<1$Eƀsfo`Ygd~^  aO & F!<<1$Eƀsfogd~^O & F!<<1$Eƀsfogd~^ [ L aO & F<<1$Eƀsfgd~^O & F<<1$Eƀsfgd~^L a\WN $Ifgd $gdugdoO & F<<1$Eƀsfgd~^O & F<<1$Eƀsfgd~^'<=AE5$xx$Ifa$gd $skd[$$Ifl0L")#%0)64 la $$Ifa$gd $;kd$$IflL")))64 laSk栗zp]NHDh6o huCJHhjFh \Sh.c^J%HhjFh.ch.cCJOJQJh.cCJOJQJ%HhjFh~^h.cCJOJQJhpDCJOJQJh \Shu^Jh~^h 7CJOJQJ$h~^h>*B*CJOJQJph$h~^hAk>*B*CJOJQJph$h~^h~^>*B*CJOJQJphh~^h~^CJOJQJh~^hAkCJOJQJAo$xx$Ifa$gd $skd $$Ifl0L")#%0)64 la xx$Ifgd $ >NOPwjj`XXX$a$gdo $a$gd $dha$gd $a$gdo$a$gdE'gduskd$$Ifl0L")#%0)64 la  >T?NP-.9]f˾Ѯќؖؐ،zzvho hCJhoho>*h~^hl8 hICJ h-%CJ ho>* hoCJ hoCJH* hoCJhoho>*CJ h >*CJ hhNCJ h CJ ho>*CJ hoCJho5CJaJhoho5CJaJhohW5CJaJ+P. !"#$%&'( $ t"a$gd $a$gdo $xa$gd #')*13luwxz{ 125>fkpqsuEFfoļ飝钇hn$hoOJQJh%UhoOJQJ ho0J.jho0J.UhPhoCJaJhKjhKU h3h{% h~^>* hoCJ h CJ h >*h~^h ho ho>*jh~^UmHnHu5()*pqrstuFgdPgd $a$gdo.HhfUUfLL $IfgdSl & F $'h]hgduJhEƀsf]hgd6oM&`#$Eƀsfgd6o-5GRSU[ѵ}rg\M\jhfhoOJQJUhfhoOJQJhQhoOJQJhIhoCJaJhuho5CJ aJ h-%hoCJaJhIhoCJaJho hNhoho0J.OJQJh~^0J.OJQJmHnHuht!ho0J.OJQJ!jht!ho0J.OJQJUht!hoOJQJhoOJQJh%UhoOJQJHTU[]QH $IfgdSl $$Ifa$gdukdI$$Ifl4F"`'pF  0`'    4 lalf4p $IfgdSlhvm`  & F $'gdAkgdP  & F $'gdu & F $'6]6gdugdSlckde$$Ifl4*`'`'0`'4 lalf4 *>?ĹĮĮČČԵձPϴϴݷ0.ϴԱ0.ϴ!0.ϴ6<hoOJQJhPhoCJaJhoh-%OJQJhuhoOJQJhQhoOJQJhoOJQJhfhoOJQJjhfhoOJQJUhXEkOJQJmHnHujhoOJQJUTUdefgh HIǿzqzmib h3h{%hsBh h h CJ h CJ hoCJ h >*CJ ho>*CJho5CJH*hKho hNhoh-%OJQJhuhoOJQJhoOJQJhPhoOJQJhXEk0J.OJQJmHnHuhPho0J.OJQJ!jhPho0J.OJQJUh $a$gdogd gdo  & F $'gdo9 0&P/R :pu/ =!"#$% =0&PP/R :pu/ =!"#$% Y$$If!vh5)#v):V l)6,5)4a$$If!vh55#%#v#v#%:V l0)6,55#%/ 4a$$If!vh55#%#v#v#%:V l0)6,55#%4a$$If!vh55#%#v#v#%:V l0)6,55#%4a$$Ifl!vh55p5F#v#vp#vF:V l4  0`'55p5F/ / / / / 4alf4p $$Ifl!vh5`'#v`':V l4*0`',5`'/ 4alf46H@H Normal1$CJOJQJ_HmH sH tH p@p  Heading 1 $h<5$7$8$9D@&H$#5CJKHOJQJ_HmH sH tH r@r  Heading 2%$h$d@&N^5CJOJQJ_HmH sH tH D@D  Heading 3$<@&5CJ>@>  Heading 4$$@&a$58@8  Heading 5$@&5B@B  Heading 6$$@&a$5CJT@T  Heading 7$ D%@&^5CJOJQJDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List vB@v 3Body Text,Body Text Char Charx^CJ_HmH sH tH hOh Step/01 Numbered  & Fx5CJOJQJ_HmH sH tH bOb Step/02 Explanation8x^8CJ_HmH sH tH \O"\ Step/04 Square Bullet & F 8^~O2~ !Step/05 Square Bullet Explanationx^CJ_HmH sH tH RO!BR Step/06 Conjunction & F^H@RH 4Header PPOJQJ_HmH sH tH R @bR Footer & F H$OJQJ_HmH sH tH :O!r: Task Name  $ujOj Body Text Bullet & F 8x^8CJ_HmH sH tH xOx Caution<2 $d&dNP^2 `CJ_HmH sH tH jOj M Header Title$1$a$#5CJ OJQJ_HaJ mH sH tH ~O~ Step/03 Explanation Bullet & F px^CJ_HmH sH tH dOd Table/Body Centered $<a$OJQJ_HmH sH tH bOb Table/Body Bullet & F#<<]# CJOJQJjOj Table/Head Left Alignedx5OJQJ_HmH sH tH HH % < Balloon TextCJOJQJ^JaJ@>@@ Title $h<@& 5CJKHBOB Illustration!$ha$LO"L Step/07 CCP Numbered " & FDOD Header Title Intro#CJnCn > Table Grid7:V$0$1$FORF Table/Body Number % & FZObZ  Style Body Text + Arial &^OJQJ>Or> End Symbol'$^a$HOH Table/Head Centered($a$POP Table/Body Left Aligned)$a$O  +Style Body Text + Arial 12 pt Before: 3 pt*<^ CJOJQJB'B ! 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