BLOOD MONITORING FORMS

INSTRUCTIONS MANUAL – revised 2005

For Quality Data Management in

Blood Service Facilities of the
National Voluntary Blood Services Program

TECHNICAL COMMITTEE
NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM
DEPARTMENT OF HEALTH
December 2000

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 BLOOD MONITORING FORMS
For Quality Data Management in
Blood Service Facilities of the
National Voluntary Blood Services Program

These Blood Monitoring Forms have been designed to standardize the reporting and collation of
data from all Blood Service Facilities under the National Voluntary Blood Services Program. The
information obtained will be used in developing strategies for quality assurance and indicators to
assess and further strengthen program implementation.

The purpose and usefulness of each form are explained. Likewise, detailed instructions for
completing the forms, definition of terms and formulas are provided. Please contact the Chairperson of
NVBSP Technical Committee, Philippine Childrens Medical Center Pediatric Blood Bank at Tel. No.
(02) 9260367 for further assistance in completing the forms. If you have comments and suggestions to
make the forms more “user friendly”, please feel free to bring them to the attention of the Technical
Committee.

The Forms should be completed by each Blood Service Facility and approved by the Blood Bank
Head. Submit a copy to the following at the end of each quarter:

1. Director IV
National Center for Health Facility Development, and
Program Manager, National Voluntary Blood Services Program
Department of Health, Sta. Cruz, Manila

2. Regional Blood Coordinator

Center for Health Development for (Region)

TECHNICAL COMMITTEE
NATIONAL VOLUNTARY BLOOD SERVICES PROGRAM
DEPARTMENT OF HEALTH
December 2000

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FORM NO : BM-01
TITLE : DONOR RECRUITMENT REPORT

PURPOSE :
To collect information on the frequency and reasons for the deferral of blood
donors.
USEFULNESS: To identify weak areas in recruitment and advocacy campaign and therefore
focus on other strategies for improvement.

INSTRUCTIONS:
1. Form BM-01 A - For Donors without Pre-donation Testing
Form BM-01 B - For Donors with Pre-donation Testing for Transfusion Transmitted Infections
2. The total no. of donors recruited is the sum of voluntary and replacement donors.
3. "Deferred by history and P.E." includes the number of donors who are temporary and permanently
deferred because of any of the following:
a. conditions elicited from interview of medical history that disqualify prospective donors
b. high-risk activities for Sexually Transmitted Infections (STIs)
c. abnormal physical examination findings

The percentage (%) is determined by dividing the total number of donors deferred by History and
P.E. by the total no. recruited multiplied by 100.

Example: No. of donors deferred by History and P.E. = 6

Total no. of donors recruited for the month = 105
% of donors deferred by History and P.E. = 6 x 100 = 5.7 %
105
4. "Deferred by laboratory testing" includes the number of donors deferred because of
a) abnormal hemoglobin
b) reactive results in any one of the transfusion transmitted diseases/infections (TTD).

The % is determined by dividing the no. of donors deferred by laboratory testing (i.e.,
Hemoglobin or TTD) by the total no. of donors recruited multiplied by 100.

Example: No. of donors deferred by abnormal Hgb = 8

Total no. of donors recruited = 105
% of donors deferred by abnormal Hgb = 8 x 100 = 7.6 %
105
5. "Other reasons" include the number of prospective donors who have no reasons for deferral but
were unable to donate because of unsuccessful phlebotomy, refusal, did not come back, anxiety
reaction, etc... List these reasons according to the frequency of occurrence in the space provided.
The % is determined by dividing the no. of donors deferred due to "other reasons" by the total
no. of donors recruited multiplied by 100. (Refer to above example)

6. "Accepted donors" include the no. of donors who have no reasons for deferral by history, P.E. and
laboratory testing and were bled successfully. Their blood unit is included in the blood inventory.
Autologous and directed donors are also included in this category.
The % is determined by dividing the no. of accepted donors by the total no. recruited
multiplied by 100. (Refer to above example)

7. The percentages determined from nos. 3, 4, 5 and 6 should have a total of 100 %.

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FORM NO. : BM-02
TITLE : CLASSIFICATION OF ACCEPTED DONORS

PURPOSE : To collect information on the overall profile of the donors per month.
USEFULNESS: To provide a general outlook of the overall implementation of the program in
terms of donor retention (repeat donors) and the advocacy campaign of the
Blood Service Facility.

INSTRUCTIONS:
1. Write the month of interest under the column "month".
2. The total number of accepted donors is the sum of the following categories:
a. new volunteer donors
b. repeat volunteer donors
c. new replacement donors
d. repeat replacement donors
e. new patient-directed donors
f. repeat patient-directed donors
3. Write the total number of donors for each category for the month of interest.

Definitions:
New Volunteer Donor - First time donor without evidence of previous donation
Repeat Volunteer Donor - Repeat donor with evidence of previous donation
New Replacement Donor - First time replacement donor in any hospital
Repeat Replacement Donor - Repeat replacement donor in the same hospital
New patient-directed donors – First time patient-directed donor in any BSF
Repeat patient-directed donors – Repeat patient-directed donor in the same BSF

 VOLUNTARY NON-REMUNERATED BLOOD DONOR – A donor who gives blood freely

and voluntarily without receiving money or any other form of payment.

Voluntary non-remunerated blood donors give blood of their own free will and receive no
money or other payment that could be considered a substitute for money. Their primary
motivation is to help unknown recipients and not to obtain any personal benefits.
The principal reasons for promoting regular voluntary non-remunerated blood donation are
as follows:
1. Voluntary non-remunerated donors have a lower incidence and prevalence of
transfusion-transmissible infections than family/replacement donors or paid donors.
They have no financial incentive to conceal information (such as high-risk sexual
behavior or a history of injecting drugs) that may have exposed them to an infection that
can be transmitted by transfusion.
2. Voluntary non-remunerated donors are more likely to be willing to donate blood
regularly, which is important in maintaining safe and adequate supplies of blood.
3. The lowest incidence and prevalence of transfusion-transmissible infections is generally
found among regular voluntary non-remunerated donors rather than first-time or
occasional donors.
4. Regular donors are not financially motivated to donate too frequently and so are not
placed at risk of anemia through the depletion of their iron stores.
5. Regular donors are also more likely to respond to an appeal for blood donors during an
emergency because they have already expressed a commitment to voluntary blood
donation.
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 FAMILY OR REPLACEMENT BLOOD DONOR – A donor who gives blood when it is
required by a member of the patient’s family or community. This may involve a hidden
paid donation system in which the donor is paid by the patient’s family.
In the absence of a well-organized national voluntary blood donation programme, many
countries rely heavily on the family or friends of patients to act as replacement donors: that
is, to give blood to replace the blood stocks used for those patients. However, research
findings from a number of countries indicate that blood from family or replacement donors
is found to be unsuitable more often than blood from voluntary non-remunerated donors
and that it therefore presents a potentially greater risk to the safety of blood supply.
A reliance on family or replacement blood donors has the following disadvantages.
1. Members of the patient’s family are under pressure to donate blood and may conceal
potentially important information about their health status, particularly the risk of
transmitting an infectious disease.
2. Relatives who cannot find suitable or willing donors within the family may seek
replacement donors who are prepared to give their blood for payment. Donors who
are paid by the patient’s family are less likely to reveal any reasons why they may be
unsuitable as donors.
3. There may be pressure to transfuse the blood that has been provided by replacement
donors, even if the transfusion is eventually clinically unnecessary, because the family
may feel that their blood should be used only for their relative.
4. In a replacement system of blood donation, the blood given to patients will not
necessarily be replaced in type or quantity. As a result, the blood needs of the
community may not be met adequately.

Where family/replacement donors are used, it is essential that the following donor
selection and screening procedures are maintained.
1. All donors should be screened prior to donation to ensure that they meet national
criteria for low-risk donors.
2. Donors should be informed that their blood will be used to replace the stock in the
blood bank and will not necessarily be given to their relative or any other named
patient.
3. The selection and screening of donors should be under the control of blood
transfusion service staff who are familiar with the correct procedures.

 PROFESSIONAL OR PAID BLOOD DONOR. A donor who gives blood for money or
other form of payment.

Professional or paid blood donors receive money or other rewards (which can be
exchanged for money) for the blood that they donate. They are usually motivated by
what they will receive for their blood rather than by a wish to help others. They often give
blood regularly and may even have a contract with a blood bank to supply for an agreed
fee. Alternatively, they may sell their blood to more than one blood bank or approach
patient’s families and try to sell their services as replacement donors.
Paid donors present a major risk to the safety of the blood supply for the following
reasons:
1. Paying donors to give blood undermines the voluntary non-remunerated system of
blood donation which is the foundation of a safe blood supply.

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 2. The highest incidence and prevalence of transfusion-transmissible infections are
generally found among commercial or paid donors.
3. They are often undernourished, in poor health and may donate their blood more
frequently than is recommended. This may have harmful effects on their own health
as well as presenting a risk to the recipients of their blood or providing little or no
benefit.
4. If donors are paid, it is usually necessary to charge their patients for the blood they
receive. Poor families may not be able to afford to pay for blood when they need it.
5. The ethical basis of paying individuals to provide blood (or any tissue or organ) is a
cause of concern in many countries. The commercial procurement of blood, plasma
and organs often leads to serious abuses and may result in adverse consequences.
These include transmission of serious infections both to patients and to the donors
themselves through improper collection methods.

4. The % for each category is determined by dividing the no. of donors by category by the total no.
of donors recruited for the month multiplied by 100.

Example: No. of New volunteer donors = 35

Total no. of donors recruited for the month = 105
% of new volunteer donors = 35 x 100 = 33.3%
105

No. of Repeat volunteer donors = 12

Total no. of donors recruited for the month = 105
% of repeat volunteer donors = 12 x 100 = 11.4%
105

5. The % of the following should have a total of 100:

a. New donors, voluntary
b. Repeat donors, voluntary
c. New donors, replacement
d. Repeat donors, replacement

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FORM NO. : BM-03
TITLE : LABORATORY REPORT FORM

PURPOSE : To collect information on the relative prevalence of Transfusion Transmitted

Diseases (TTDs) among donated blood units; To collect information on the
Quality of screening for TTDs through the accuracy of testing and test kit
performance over time.
USEFULNESS: To provide relative prevalence of TTDs among donated blood units and
develop strategies for Quality Assurance for Blood Service Facilities (BSF).

INSTRUCTIONS:
1. Form BM-03 A - shall be used for donors recruited in Blood Service Facilities (BSF) only.
Form BM-03 B – shall be used for re-screening of blood/blood products obtained
outside the BSF.
2. Under the column "Units of blood tested", write the total number of blood units tested for the month
by disease.

3. "Initial Reactivity (IR)" includes the no. of blood units that are initially reactive on the first
screening or testing.

% IR = No. of Initially Reactive blood units (First screen) x 100

Total no. of blood units tested

4. "Repeat Reactivity (RR)" includes the no. of initially reactive blood units that are reactive on repeat
testing (repeat reactors) using the same sample and the same test kit.

% RR = No. of Reactive blood units on repeat testing x 100

Total no. of blood units tested

5. Laboratory Error Rate (Lab Error %) = % IR - % RR.

6. Accuracy is the proportion of blood units with correct results among the total no. of units referred to
RITM for confirmation.

%Accuracy = No. of units with correct results (per RITM confirmation) x 100
Total no. of units sent to RITM for confirmation

7. Positive Predictive Value (PPV) is the probability of disease/infection in a donor with a positive
test result.

%PPV = No. of units confirmed Positive (per RITM result) x 100

Total no. of Repeat Reactors

8. Seroprevalence = No. of confirmed Positive blood units for the month x 100
Total no. of blood units tested for the month

9. Seroprevalence (To date) is the cumulative seroprevalence from the start of the year up to the
month of interest. It provides seroprevalence data at any point in time.

Seroprevalence (To date) = No. of confirmed Positive from start of the year to date x 100
Total no. of blood units tested from start of year to date

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FORM NO. : BM- 04
TITLE : BLOOD USAGE MONITORING REPORT FORM

PURPOSE : To collect information on the number of units requested, cross-matched and

were actually transfused. To monitor blood usage in the hospital. To
determine C/T ratio.
USEFULNESS: To have a general outlook on the nature of the hospital, it’s patients’ need for
blood and correct blood use. To develop strategies for rational blood use
among prescribers of blood.

INSTRUCTION:

 Tally all blood and blood components according to blood units requested, served and
transfused.

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FORM NO. : BM-05
TITLE : BLOOD DONATIONS DOCUMENTATION REPORT

PURPOSE :
To collect information on the ABO Blood Type distribution according to
sources of blood donations.
USEFULNESS: To gain knowledge on the advocacy campaign of the Blood Service Facility

INSTRUCTIONS:
1. Form BM-05 A – shall be completed for Screened/Tested donors only.
Form BM-05 B - shall be completed for patient directed and autologous donations.

2. Definition of sources of blood donations:

a. Mass blood donations - blood units collected from voluntary donors outside of the Blood
Service Facility (BSF); field donations
b. Walk-in voluntary Blood donations - blood units collected from volunteer donors who come to
the BSF and donate.
c. In-house donations - blood units collected from the staff and/or employees of the BSF.
d. Replacement donations - blood units collected from donors and exchanged for units used.
e. Patient directed donations - blood units collected from donors and assigned to a specified
recipient.
f. Autologous donations - blood is collected from a donor-patient.

3. For each source of blood donation, write the number of blood units according to Blood Type by
month and TOTAL for the quarter (sum of all units by blood type for the reporting months).

The monthly % for each blood type is determined by dividing the no. of units per blood type by the
sub-total number of units regardless of blood type multiplied by 100.

Example: In-house donations for March = 30 'u' of Blood Type 'O'+ Total no.
of units, ALL Blood Types for March = 42
% of Blood Type 'O' for March = 30 x 100
42
= 71 %

The quarterly % is determined by dividing the TOTAL for each Blood Type by the TOTAL number
of units for all blood types multiplied by 100.

Example: January = 15 'u' of Blood Type 'O'+

February = 10 “
March = 30 “
Total = 55 “
Total no. of units, ALL Blood Types collected in-house = 200

% ‘O’+, In-house = Total no. of units with Blood Type 'O', In-House x 100
Total no. of units for ALL blood types, In-house
= 55 x 100
200
= 27 %

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Form BM-05 cont….

4. The GRAND TOTAL is the sum of all blood units regardless of blood type and source of donation.
This is determined by adding the SUB-TOTALS for all sources by month of interest and Totals for
the quarter.

The % by month for ALL sources is determined by dividing the GRAND TOTAL for the month by
the GRAND TOTAL for the quarter multiplied by 100.

% by Month, all sources = GRAND TOTAL for the month x 100

GRAND TOTAL for the quarter

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FORM NO. : BM- 06
TITLE : INVENTORY OF BLOOD RECEIVED FORM

PURPOSE : To collect information on the major source of blood/blood products in

the Blood Service Facility.
USEFULNESS: To get an overview on the demand, use of blood/blood products and
recruitment/advocacy campaign of the Blood Service Facility.

INSTRUCTIONS:

1. Write the number of units according to blood component and source by month.
a. Lead hospital – provides the majority of blood supply to satellite hospitals within the zonal
network.
b. Swapping - includes the number of units exchanged for another blood product, blood bags or
the like.
c. PNRC – Phil. Natl. Red Cross maybe a major source of blood and blood products.
d. Satellite hospitals – receives blood/blood products from lead hospitals within the zonal
network and other sources as necessary.

2. The % of a blood component/WB is determined by dividing the no. of blood component/WB by the
total no. of blood components/WB received for the month, by source multiplied by 100.

Example:
SOURCE Reporting Months
Lead BSF January February March TOTAL
No. % No. % No. % No. %
PRBC 13 50 10 10 33 47
Fresh Frozen Plasma 4 15 2 2 8 11
Cryoprecipitate 2 8 1 2 5 7
Platelet Concentrate 4 15 4 5 13 19
Cryosupernate 0 0 1 0 1 1
Whole Blood 3 12 3 4 10 14
Sub-total 26 21 23 70

Example: % PRBC = No. of units received in January x 100

Total no. of components/WB in January
= 13 x 100
26
= 50%

3. The TOTAL no. of blood components/WB by source received for the quarter is the sum of all the
blood/blood components for the reporting months.

The % by quarter is determined by dividing the TOTAL no. for each component/WB by the total
number of ALL components/WB received for the source.

Example: % PRBC = No. of units received for the Quarter x 100

Total no. of ALL components/WB for Qtr.
= 13 + 10 + 10 = 33 x 100
26 + 21 + 23 70
= 47 %

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Form No.: BM-06 Cont….

4. The GRAND TOTAL is the sum of ALL blood and blood components regardless of source of
receipt. This is determined by adding the SUB-TOTALS for all sources by month and
TOTALS for the Quarter.

The % by month for ALL sources is determined by dividing the GRAND TOTAL for the month
by the GRAND TOTAL for the quarter multiplied by 100.

% by Month, all sources = GRAND TOTAL for the month x 100

GRAND TOTAL for the quarter

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FORM NO. : BM- 07
TITLE : INVENTORY OF BLOOD DISPENSED FORM

PURPOSE :
To collect information on the blood/blood products made available by the
Blood Service Facility.
USEFULNESS: To get an overview on the availability, use of blood /blood components and
distribution in the Blood Service Facility.

INSTRUCTIONS:
1. Write the No. of blood/blood components dispensed to the recipient institutions:
a. Satellite hospitals
b. Lead and other hospitals
c. In-house patients of the Blood Service Facility (BSF)
d. patients/relatives not included in (c), if applicable, use separate sheet
2. Blood units dispensed also include those that are exchanged for other blood components, blood
bags, screening fees, etc…
3. The % of a component dispensed for the month is determined by dividing the no. of
components/WB by the total no. of components/WB dispensed for the month X 100.

Example:
Recipient Reporting Months
Institution January February March TOTAL
Satellite BSF No. % No. % No. % No. %
PRBC 13 50 10 10 33 47
Fresh Frozen Plasma 4 15 2 2 8 11
Cryoprecipitate 2 8 1 2 5 7
Platelet Concentrate 4 15 4 5 13 19
Cryosupernate 0 0 1 0 1 1
Whole Blood 3 12 3 4 10 14
Sub-total 26 21 23 70

Example: % FFP = No. of units dispensed in January x 100

Sub-Total no. of units dispensed in January
= 4 x 100
26
= 15 %

4. The TOTAL no. of blood components/WB by source dispensed for the quarter is the sum of all
the blood/blood components for the reporting months.

The % for the quarter is determined by dividing the TOTAL no. for each component/WB by the
total number of ALL components/WB dispensed for the source and quarter.

Example: % FFP = No. of units dispensed for the Quarter x 100

Total no. of ALL components/WB for Qtr.
= 4 + 2 + 2 = 8 x 100
26 + 21 + 23 70
= 12 %

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Form No.: BM-07 Cont…..

5. The GRAND TOTAL is the sum of ALL blood and blood components regardless of recipient
institution. This is determined by adding the SUB-TOTALS for all recipient institutions by month
and TOTALS for the Quarter.

The % by month for ALL recipient institutions is determined by dividing the GRAND TOTAL for
the month by the GRAND TOTAL for the quarter multiplied by 100.

% by Month, all institutions = GRAND TOTAL for the month x 100

GRAND TOTAL for the quarter

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FORM NO. : BM- 08
TITLE : BLOOD INVENTORY CONTROL REPORT

PURPOSE : To collect information on the availability and use of blood/blood products in

the Blood Service Facility.
USEFULNESS: To provide a mechanism of audit and basis for the Maximum Blood
Ordering Schedule (MBOS) in the Blood Service Facility.

INSTRUCTIONS:
1. Write the number of units prepared and received.
2. The No. of units dispensed should be equal to the TOTAL No. reported in the INVENTORY OF
BLOOD DISPENSED (Form No. BM-07).
3. Unused units include:
a) Outdated units - units that have reached expiry and are not assigned.
% Outdated Units = No. of Outdated Units x 100
Total No. of Units for the month

% Outdated WB = 1 x 100
30
= 3%
b) Others - include units from transfusions which have been stopped; may include other reasons
such as punctured blood units, hemolyzed, wastage, etc….
% Other Unused Units = No. of Other unused units x 100
Total No. of Units for the month
Example:

Month: No. of
January Total No. of Units Units Unused Units Ending
Dispense Others Balanc
Balance from d Outdated ** e
PreviousMon Prepare Receiv
Product th d ed No. % No. %
Whole Blood 10 10 10 10 1 3 1 3 18
Packed RBC
Fresh Frozen
Plasma
Cryoprecipitate
Cryosupernate
Platelet
Concentrate
Others:
* * Please list reasons:

4. Ending Balance – Total no. of units available for assignment.

5. Put an asterisk (*) if processing is done outside Blood Service Facilities (BSF).
6. List reasons (**) in the space below the table.

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