The ASBBC Form 044 serves an essential purpose in assessing individuals' travel history to specific regions across the globe, especially concerning eligibility and safety in blood donation. Crafted meticulously, this form spans two pages, beginning with the request for personal identifiers like a full name and Social Security Number to ensure data accuracy and protect privacy as outlined in the accompanying DD Form 572. It targets detailed travel history through a series of pointed questions, starting with cumulative travel in the United Kingdom from 1980 to 1996, broadening out to encompass time spent in Eastern or Western Europe, the Middle East, and certain African countries with a noted risk for Bovine Spongiform Encephalopathy (BSE). Additionally, it addresses recent travel to the Republic of Korea, probing further based on the duration and specific locations visited within the country. Each section is designed for clear interviewer guidance with checkboxes to streamline the process and make it easy for respondents to provide accurate information. This diligence in gathering travel data underscores the meticulous efforts to safeguard the health of blood donors and recipients alike, highlighting the ASBBC's commitment to maintaining high safety standards in its blood bank operations. The ASBBC Form 044, revised in October 2010 and issued by the Armed Services Blood Bank Center in Bethesda, MD, reflects a robust process of evaluating potential risk factors that might affect blood supply safety, encapsulating a crucial step in the meticulous screening process for blood donors.
| Question | Answer |
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| Form Name | Asbbc Form 044 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | GUERNESY, GEORGIA, dd 572 form, Oct2010 |
FOREIGN COUNTRY TRAVEL INFORMATION (Page 1 of 2)
Full Name________________________________ SSN__________________
This form remains attached to the DD Form 572 and is protected by the Privacy Act Statement as detailed on the DD Form 572.
PLEASE REFER TO THE COUNTRIES ASSOCIATED WITH A RISK FOR BSE IN THE BLOOD DONOR INFORMATION BINDER TO ANSWER QUESTIONS
QUESTION 1 (CUMULATIVE UNITED KINGDOM TRAVEL):
From the beginning of 1980 through the end of 1996, have you spent time that adds up to 90 days (3 months) or more in the United Kingdom (UK)?
□ YES, PLEASE CHECK BELOW |
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□ NO, SKIP TO QUESTION 2 |
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□ UNITED KINGDOM |
□ NORTHERN |
IRELAND |
□ SOUTH SANDWICH ISLANDS |
□ CHANNEL ISLANDS |
□ SCOTLAND |
□ ALDERNEY |
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□ ENGLAND |
□ WALES |
□ GUERNESY |
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□ FALKLAND ISLANDS |
□ SOUTH GEORGIA ISLANDS |
□ SARK |
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□ GIBRALTAR |
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□ JERSEY |
□ THE ISLE OF MAN |
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INTERVIEWER USE ONLY
QUESTION 2 (CUMULATIVE EUROPEAN/MIDDLE EASTERN TRAVEL):
From the beginning of 1980 through the end of 1996, have you spent time
that adds up to 180 days (6 months) or more in Eastern or Western Europe,
or the Middle East?
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YES, PLEASE CHECK BELOW |
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□ NO, SKIP TO QUESTION 3 |
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Eastern Europe |
□ Western Europe |
□ Middle East |
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INTERVIEWER USE ONLY |
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QUESTION 3 (CUMULATIVE EUROPEAN/MIDDLE EASTERN TRAVEL):
From the beginning of 1980 to the present, have you spent time that adds up to five (5) years in Eastern or Western Europe, or the Middle East? (Not to include the UK)
□ YES, PLEASE CHECK BELOW
□ NO, SKIP TO QUESTION 4
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□ Eastern Europe |
□ Western Europe |
□ Middle East |
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INTERVIEWER USE ONLY |
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QUESTION 4: |
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Have you been to any of the following countries since 1977? |
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□ YES, PLEASE CHECK BELOW |
□ NO, SKIP TO QUESTION 5 |
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□ CAMEROON |
□ CHAD |
□ GABON |
□ BENIN |
□ TOGO |
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□ CENTRAL AFRICAN |
□ CONGO |
□ NIGER |
□ KENYA |
□ ZAMBIA |
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REPUBLIC |
□ EQUATORIAL GUINEA |
□ NIGERIA |
□ SENEGAL |
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INTERVIEWER USE ONLY
ADDITIONAL QUESTIONS ON REVERSE
Armed Services Blood Bank Center, Bethesda, MD |
ASBBC Form 044 (Oct2010) |
FOREIGN COUNTRY TRAVEL INFORMATION (Page 2 of 2)
Full Name________________________________ SSN__________________
QUESTION 5:
Have you been to the Republic of Korea in the past 3 years (36 months)?
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□ YES, ANSWER QUESTION 5a |
□ NO, SKIP TO QUESTION 6 |
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QUESTION 5a: |
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While assigned to Korea, were you stationed or did you travel to any area
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North of |
Seoul (North of the 37.7 Parallel)? |
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□ YES, ANSWER QUESTION 5b |
□ NO, SKIP TO QUESTION 6 |
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QUESTION |
5b: |
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Were you |
in the Republic of Korea, North of Seoul greater than 5 consecutive |
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years? |
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□ YES, ANSWER QUESTION 5c |
□ NO, ANSWER QUESTION 5c |
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QUESTION |
5c: |
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What month and year did you leave the area?
INTERVIEWER USE ONLY
QUESTION 6:
Please list any country where you have been in the last 3 years (36
months):
COUNTRY
AREAS VISITED
Were you in the
country greater than 5 consecutive years?
Date
Arrived
Date
Departed
INTERVIEWER USE ONLY
Date
Place Unit Number Sticker Here
Donor Signature |
Interviewer Signature |
Armed Services Blood Bank Center, Bethesda, MD |
ASBBC Form 044 (Oct2010) |