Questions 1 – 2: Was hemoglobin electrophoresis performed? (do not include results if an RBC transfusion occurred within 4 weeks of the electrophoresis study)

Indicate if hemoglobin electrophoresis studies were performed in the current reporting period. If a hemoglobin electrophoresis studies were not performed or it is not known if performed, select No or Unknown, respectively and continue with question 16.

If a hemoglobin electrophoresis study was performed but RBC transfusion(s) were given within four weeks prior to the study, select Not applicable and continue with question 16.

If Yes, report the date of them most recent hemoglobin electrophoresis study performed in the reporting period. If the exact date is not known report an estimated date and check the Date estimated box. Refer to General Instructions, General Guidelines for Completing Forms for information about reporting estimated dates.

Questions 3 – 15: Specify the hemoglobin allele types based on the sample tested above

Specify the hemoglobin types identified in the reported hemoglobin study (reported in question 2). If the hemoglobin allele type was assessed, report Yes and specify the percentage.

If additional thalassemia related hemoglobin types are identified but not listed as options on the form, select Yes for Other thalassemia related hemoglobin type, specify the other hemoglobin type, and the report the percentage.

Section Updates:

Question Number Date of Change Add/Remove/Modify Description Reasoning (If applicable)
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Last modified: Apr 24, 2022

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