Asbbc Form 044 – Fill Out and Use This PDF

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 1-3:

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		□ NO, SKIP TO QUESTION 2
□ UNITED KINGDOM	□ NORTHERN	IRELAND	□ SOUTH SANDWICH ISLANDS
□ CHANNEL ISLANDS	□ SCOTLAND		□ ALDERNEY
□ ENGLAND	□ WALES		□ GUERNESY
□ FALKLAND ISLANDS	□ SOUTH GEORGIA ISLANDS		□ SARK
□ GIBRALTAR			□ JERSEY
□ THE ISLE OF MAN

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?

□	YES, PLEASE CHECK BELOW		□ NO, SKIP TO QUESTION 3
□	Eastern Europe	□ Western Europe		□ Middle East
INTERVIEWER USE ONLY

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)

	□ Eastern Europe		□ Western Europe		□ Middle East
	INTERVIEWER USE ONLY
	QUESTION 4:
	Have you been to any of the following countries since 1977?
	□ YES, PLEASE CHECK BELOW			□ NO, SKIP TO QUESTION 5
	□ CAMEROON		□ CHAD	□ GABON	□ BENIN	□ TOGO
	□ CENTRAL AFRICAN		□ CONGO	□ NIGER	□ KENYA	□ ZAMBIA
	REPUBLIC		□ EQUATORIAL GUINEA	□ NIGERIA	□ SENEGAL

INTERVIEWER USE ONLY

ADDITIONAL QUESTIONS ON REVERSE

Armed Services Blood Bank Center, Bethesda, MD 20889-5600

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)?

	□ YES, ANSWER QUESTION 5a		□ NO, SKIP TO QUESTION 6
	QUESTION 5a:

While assigned to Korea, were you stationed or did you travel to any area

	North of	Seoul (North of the 37.7 Parallel)?
	□ YES, ANSWER QUESTION 5b			□ NO, SKIP TO QUESTION 6
	QUESTION	5b:
	Were you	in the Republic of Korea, North of Seoul greater than 5 consecutive
	years?
	□ YES, ANSWER QUESTION 5c			□ NO, ANSWER QUESTION 5c
	QUESTION	5c:

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):

INTERVIEWER USE ONLY

Date

Place Unit Number Sticker Here

Donor Signature

Interviewer Signature

Armed Services Blood Bank Center, Bethesda, MD 20889-5600

ASBBC Form 044 (Oct2010)