Thank you for participating in the 4 hour post-transfusion Initial Data Collection Form: US Expanded Access Program for Convalescent Plasma for the Treatment of Patients with COVID-19.

NOTE: Mayo Clinic will serve as the IRB of record. You are required by Federal Regulation to report Serious Adverse Events (SAEs), which are found in this Initial Data Collection Form (4-hour post-transfusion/unable to transfuse).

The Initial Data Collection (4-hour) Form should be completed for each enrolled patient, regardless of circumstances. For example, the form should be filled out even if plasma was never ordered or plasma was ordered but not transfused.

Please fill in the form with as much detail as possible.

Please use the unique patient code assigned at the time of enrollment to complete the form.

The purpose of the study is to provide access to investigational convalescent plasma for patients in acute care facilities infected with SARS-CoV-2 who have severe or life-threatening COVID-19, or who are judged by a healthcare provider to be at high risk of progression to severe or life-threatening disease.

Information, protocol, consent forms and site registration, enrollment and followup forms are available at www.USCOVIDplasma.org.

If you have any questions or difficulties please email USCOVIDplasma@mayo.edu, which will be monitored from 7am-7pm CST.

Note: Submission of this form on iOS devices using Safari may cause duplicate submissions. If possible, please submit from another browser such as Google Chrome, Internet Explorer, or Mozilla Firefox. Thank you.

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