TGA use only
This form, when completed, will be classified as 'For official use only'.
For guidance on how your information will be treated by the TGA see: Treatment of information provided to the TGA at
<http://www.tga.gov.au/about/tga-information-to.htm>.
Human blood and tissues recall report
 This form is used to report recalls of human blood and tissue products.
 Recalls must be reported as soon as possible to recalls@tga.gov.au, and by telephone or
facsimile to the Deputy Australian Recall Co-ordinator Telephone: 02 6232 8935, Mobile: 0412
205 568 (AH) Facsimile: 02 6232 1451
1.
Date of problem:
2.
Reporter (person reporting the problem):
Name:
Occupation/Position:
Institution:
Address:
Telephone:
Facsimile:
Email:
3.
Product name(s):
4.
Primary donation/tissue
bank number:
5.
Secondary Identifier
number (where applicable):
6.
Donation type:
Expiry date:
PO Box 100 Woden ACT 2606 ABN 40 939 406 804
Phone: 1800 020 653 Fax: 02 6203 1605 Email: info@tga.gov.au http://www.tga.gov.au
7.
Reason for recall:
8.
Source of failure (if known):
9.
Date: of donation
and of issue:
10. Has the recipient hospital/pathologist/fractionator been contacted?
Yes
No
Details:
Signature:
Human blood and tissues recall report (August 2014)
For official use only
Date:
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