Use This Form BLANK Blood Monitoring Report From RVBSP

FORM NO.
: BM-01
Name of Hospital/PNRC Chapter:
Center for Health Development for: Qtr: Year:
TITLE : DONOR RECRUITMENT REPORT WITHOUT PRE-DONATION TESTING
Form BM-01 A
Deferred by Lab. Testing

Total No. of Deferred by History Infectious Diseases
Month Donors & PE Abnormal Hgb (TTDs) Other Reasons* Accepted
No. % No. % No. % No. % No.
TOTAL
Month Total
Other Reasons* No. % No. % No. % No. %
FORM BM-01 B
TITLE : DONOR RECRUITMENT REPORT WITH PRE-DONATION TESTING
Deferred by Lab. Testing

Total No. of Deferred by History Infectious Diseases
Month Donors & PE Abnormal Hgb (TTDs) Other Reasons* Accepted and Ble
No. % No. % No. % No. % No.
TOTAL
Month Total
Other Reasons* No. % No. % No. % No. %
Prepared by:
____________________________________
Printed Name & Signature
Designation
REPORT WITHOUT PRE-DONATION TESTING
Accepted
%
T REPORT WITH PRE-DONATION TESTING
Accepted and Bled

%
FORM NO.: BM-02
Name of Hospital/PNRC Chapter: _____________________________________________________________________

Center for Health Development for: _______________________________________ Qtr: Year :
TITLE : CLASSIFICATION OF ACCEPTED BLOOD DONORS
INDICATORS
Month Total No. VOLUNTARY REPLACEMENT PATIENT-DIRECTED
of Accepted New Donors Repeat Donors New Donors Repeat Donors New Donors Repeat Donors
Donations No. % No. % No. % No. % No. % No. %
TOTAL
Remarks: Include Mass Blood Donations (MBD) under Voluntary
Prepared by:
____________________________________
Designation
FORM NO.: BM-03 A

TITLE : LABORATORY REPORT FORM FOR DONORS RECRUITED IN BSF ONLY

(Transfusion Transmitted Diseases Screening)
Summary for the Month of :

Seroprevalence (
Disease IR RR Lab. Error Accuracy PPV date)**
No. of Blood Sero-
Units Tested * No. % No. % % % % prevalence No. Tested
HBV
Syphilis
Malaria
HIV
HCV

Seroprevalence (
No. of Blood Sero-
HBV
Syphilis
Malaria
HIV
HCV

Seroprevalence (
No. of Blood Sero-
HBV
Syphilis
Malaria
HIV
HCV
* Units of Blood Tested for the month by disease

** Cumulative data from current year to reporting month
Prepared by:
____________________________________
Designation
Year:
T FORM FOR DONORS RECRUITED IN BSF ONLY

Transmitted Diseases Screening)
Seroprevalence (To
date)**
%
Seroprevalence (To
date)**
%
Seroprevalence (To
date)**
%
FORM NO.: BM-03 B

TITLE : LABORATORY REPORT ON RE-SCREENING OF BLOOD/BLOOD PRODUCTS FROM

OUTSIDE SOURCES (Transfusion Transmitted Diseases Screening)

Seroprevalence
Disease IR RR Lab. Error Accuracy PPV (To date)**
No. of Blood Sero-
HBV
Syphilis
Malaria
HIV
HCV

Seroprevalence
No. of Blood Sero-
HBV
Syphilis
Malaria
HIV
HCV

Seroprevalence
No. of Blood Sero-
HBV
Syphilis
Malaria
HIV
HCV
* Units of Blood Tested for the month by disease

** Cumulative data from current year to reporting month
Prepared by:
____________________________________
Designation
Year:
RE-SCREENING OF BLOOD/BLOOD PRODUCTS FROM
Seroprevalence
(To date)**
%
Seroprevalence
(To date)**
%
Seroprevalence
(To date)**
%
FORM NO.: BM-04
Name of Hospital/PNRC Chapter: _______________________________________________________________
Center for Health Development for: ______________________________________________________
TITLE : BLOOD USAGE MONITORING REPORT
Crossmatched*/Transfused Ratio
No. of units No. of units

Blood and Blood Products No. of units REQUESTED CROSSMATCHED TRANSFUSED
Month: _________
Whole Blood (WB)
Packed Red Blood Cells (PRBC)
Fresh Frozen Plasma (FFP)
Cryosupernate (CryoS)
Cryoprecipitate (CryoP)
Platelet Concentrate (Pltcon)
Others (Specify):
Month: _________
Whole Blood (WB)
Others (Specify):
Month: _________
Whole Blood (WB)
Others (Specify):
____________________________________________
Year: _______________
SAGE MONITORING REPORT
C/T Ratio
FORM NO.: BM-05A

Center for Health Development for: Qtr: YEAR:
TITLE : BLOOD DONATIONS DOCUMENTATION REPORT (SCREENED/TESTED)
SOURCES REPORTING MONTHS

Mass Blood TOTAL
Donations No. % No. % No. % No. %
O+
A+
B+
AB+
Others
SUB-TOTAL
Walk-in Voluntary TOTAL

Blood Donations No. % No. % No. % No. %
O+
A+
B+
AB+
Others
SUB-TOTAL
In-House TOTAL
Donations No. % No. % No. % No. %
O+
A+
B+
AB+
Others
SUB-TOTAL
Replacement TOTAL
No. % No. % No. % No. %
O+
A+
B+
AB+
Others
SUB-TOTAL
GRAND TOTAL
Prepared by:
____________________________________
Designation
FORM NO.: BM-05 B

Center for Health Development for: Qtr: YEAR:
TITLE : BLOOD DONATIONS DOCUMENTATION REPORT

(FOR PATIENT DIRECTED AND AUTOLOGOUS DONATIONS)

DIRECTED TOTAL
Donations No. % No. % No. % No.
O+
A+
B+
AB+
Others
SUB-TOTAL
AUTOLOGOUS TOTAL
Donations No. % No. % No. % No.
O+
A+
B+
AB+
Others
SUB-TOTAL
GRAND TOTAL
Prepared by:
____________________________________
Designation
IONS DOCUMENTATION REPORT
D AND AUTOLOGOUS DONATIONS)
REPORTING MONTHS
TOTAL
%
TOTAL
%
TITLE : INVENTORY OF BLOOD RECEIVED

LEAD BLOOD TOTAL
SERVICE FACILITY (BSF) No. % No. % No. % No. %
Packed Red Blood Cell
Fresh Frozen Plasma
Cryoprecipitate
Platelet Concentrate
Cryosupernate
Whole Blood
SUB-TOTAL
SATELLITE BSF TOTAL

Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Whole Blood
SUB-TOTAL
PNRC TOTAL
Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Whole Blood
SUB-TOTAL
COMMERCIAL BLOOD BANK TOTAL
Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Whole Blood
SUB-TOTAL
Other Sources * TOTAL
SUB-TOTAL
GRAND TOTAL
* Other sources not within the zonal network (MOA); Please list type of blood product
Prepared by:
____________________________________
Designation
FORM NO.: BM-07

TITLE : INVENTORY OF BLOOD PRODUCTS DISPENSED
RECIPIENT INSTITUTION REPORTING MONTHS

TOTAL
SATELLITE BSF within the
Zonal Network (MOA) No. % No. % No. % No.
Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Whole Blood
Others:
SUB-TOTAL
OTHER HOSPITALS * outside the TOTAL

Zonal Network (MOA) No. % No. % No. % No.
Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Whole Blood
Others:
SUB-TOTAL
* includes units bloods dispensed to hospitals not within the zonal network (MOA)
IN-HOUSE TOTAL
No. % No. % No. % No.
Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Whole Blood
Others:
SUB-TOTAL
GRAND TOTAL
* Other sources not within the zonal network (MOA); Please list type of blood product
Prepared by:
____________________________________
Designation
OF BLOOD PRODUCTS DISPENSED
REPORTING MONTHS
TOTAL
%
TOTAL
%
TOTAL
%
FORM NO.: BM-08

TITLE : BLOOD INVENTORY CONTROL REPORT
Month: Total No. of Units No. of Units Unused Units Ending

Balance from Dispensed Outdated Others ** Balance
Product PreviousMonth Prepared Received No. % No. %
Whole Blood
Packed RBC
Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Others:

Whole Blood
Packed RBC
Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Others:

Whole Blood
Packed RBC
Fresh Frozen Plasma
Cryoprecipitate
Cryosupernate
Others:
* Put an asterisk if processing done outside BSF

** Others also include punctured blood units, hemolyzed, wastage, etc….
Prepared by:
CAREN MAY DANDIN

Medical Technologist II
Designation

Use This Form BLANK Blood Monitoring Report From RVBSP

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FORM NO.

TITLE : DONOR RECRUITMENT REPORT WITHOUT PRE-DONATION TESTING

Deferred by Lab. Testing

Deferred by Lab. Testing

T REPORT WITH PRE-DONATION TESTING

Accepted and Bled

Name of Hospital/PNRC Chapter: _____________________________________________________________________

TITLE : CLASSIFICATION OF ACCEPTED BLOOD DONORS

Name of Hospital/PNRC Chapter:

TITLE : LABORATORY REPORT FORM FOR DONORS RECRUITED IN BSF ONLY

Summary for the Month of :

Summary for the Month of :

Summary for the Month of :

* Units of Blood Tested for the month by disease

T FORM FOR DONORS RECRUITED IN BSF ONLY

Name of Hospital/PNRC Chapter:

TITLE : LABORATORY REPORT ON RE-SCREENING OF BLOOD/BLOOD PRODUCTS FROM

Summary for the Month of :

Summary for the Month of :

Summary for the Month of :

* Units of Blood Tested for the month by disease

RE-SCREENING OF BLOOD/BLOOD PRODUCTS FROM

TITLE : BLOOD USAGE MONITORING REPORT

No. of units No. of units

SAGE MONITORING REPORT

Name of Hospital/PNRC Chapter:

TITLE : BLOOD DONATIONS DOCUMENTATION REPORT (SCREENED/TESTED)

SOURCES REPORTING MONTHS

Walk-in Voluntary TOTAL

Name of Hospital/PNRC Chapter:

TITLE : BLOOD DONATIONS DOCUMENTATION REPORT

SOURCES REPORTING MONTHS

TITLE : INVENTORY OF BLOOD RECEIVED

SOURCES REPORTING MONTHS

SATELLITE BSF TOTAL

Name of Hospital/PNRC Chapter:

TITLE : INVENTORY OF BLOOD PRODUCTS DISPENSED

RECIPIENT INSTITUTION REPORTING MONTHS

OTHER HOSPITALS * outside the TOTAL

Name of Hospital/PNRC Chapter:

TITLE : BLOOD INVENTORY CONTROL REPORT

Month: Total No. of Units No. of Units Unused Units Ending

Month: Total No. of Units No. of Units Unused Units Ending

Month: Total No. of Units No. of Units Unused Units Ending

* Put an asterisk if processing done outside BSF

CAREN MAY DANDIN

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