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:

____________________________________
Printed Name & Signature
Designation
 FORM NO.: BM-03 A

Name of Hospital/PNRC Chapter:

Center for Health Development for: Qtr: Year:

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

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

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

* Units of Blood Tested for the month by disease

** Cumulative data from current year to reporting month

Prepared by:

____________________________________
Printed Name & Signature
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

Name of Hospital/PNRC Chapter:

Center for Health Development for: Qtr: Year:

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

OUTSIDE SOURCES (Transfusion Transmitted Diseases Screening)

Summary for the Month of :

Seroprevalence
Disease IR RR Lab. Error Accuracy PPV (To date)**
No. of Blood Sero-
Units Tested * No. % No. % % % % prevalence No. Tested

HBV

Syphilis

Malaria

HIV

HCV

Summary for the Month of :

Seroprevalence
Disease IR RR Lab. Error Accuracy PPV (To date)**
No. of Blood Sero-
Units Tested * No. % No. % % % % prevalence No. Tested

HBV

Syphilis

Malaria

HIV

HCV

Summary for the Month of :

Seroprevalence
Disease IR RR Lab. Error Accuracy PPV (To date)**
No. of Blood Sero-
Units Tested * No. % No. % % % % prevalence No. Tested

HBV

Syphilis

Malaria

HIV

HCV

* Units of Blood Tested for the month by disease

** Cumulative data from current year to reporting month

Prepared by:

____________________________________
Printed Name & Signature
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)
Packed Red Blood Cells (PRBC)
Fresh Frozen Plasma (FFP)
Cryosupernate (CryoS)
Cryoprecipitate (CryoP)
Platelet Concentrate (Pltcon)
Others (Specify):

Month: _________
Whole Blood (WB)
Packed Red Blood Cells (PRBC)
Fresh Frozen Plasma (FFP)
Cryosupernate (CryoS)
Cryoprecipitate (CryoP)
Platelet Concentrate (Pltcon)
Others (Specify):
____________________________________________
Year: _______________

SAGE MONITORING REPORT

C/T Ratio
 FORM NO.: BM-05A

Name of Hospital/PNRC Chapter:

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:

____________________________________
Printed Name & Signature
Designation
FORM NO.: BM-05 B

Name of Hospital/PNRC Chapter:

Center for Health Development for: Qtr: YEAR:

TITLE : BLOOD DONATIONS DOCUMENTATION REPORT

(FOR PATIENT DIRECTED AND AUTOLOGOUS DONATIONS)

SOURCES REPORTING MONTHS

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:

____________________________________
Printed Name & Signature
Designation
IONS DOCUMENTATION REPORT
D AND AUTOLOGOUS DONATIONS)

REPORTING MONTHS
TOTAL
%

TOTAL
%
Name of Hospital/PNRC Chapter:
Center for Health Development for: Qtr: Year:

TITLE : INVENTORY OF BLOOD RECEIVED

SOURCES REPORTING MONTHS

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

Packed Red Blood Cell
Fresh Frozen Plasma
Cryoprecipitate
Platelet Concentrate
Cryosupernate
Whole Blood
SUB-TOTAL

PNRC TOTAL
Packed Red Blood Cell
Fresh Frozen Plasma
Cryoprecipitate
Platelet Concentrate
Cryosupernate
Whole Blood
SUB-TOTAL
COMMERCIAL BLOOD BANK TOTAL
Packed Red Blood Cell
Fresh Frozen Plasma
Cryoprecipitate
Platelet Concentrate
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:

____________________________________
Printed Name & Signature
Designation
 FORM NO.: BM-07

Name of Hospital/PNRC Chapter:

Center for Health Development for: Qtr: Year:

TITLE : INVENTORY OF BLOOD PRODUCTS DISPENSED

RECIPIENT INSTITUTION REPORTING MONTHS

TOTAL
SATELLITE BSF within the
Zonal Network (MOA) No. % No. % No. % No.
Packed Red Blood Cell
Fresh Frozen Plasma
Cryoprecipitate
Platelet Concentrate
Cryosupernate
Whole Blood
Others:
SUB-TOTAL

OTHER HOSPITALS * outside the TOTAL

Zonal Network (MOA) No. % No. % No. % No.
Packed Red Blood Cell
Fresh Frozen Plasma
Cryoprecipitate
Platelet Concentrate
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.
Packed Red Blood Cell
Fresh Frozen Plasma
Cryoprecipitate
Platelet Concentrate
Cryosupernate
Whole Blood
Others:
SUB-TOTAL

GRAND TOTAL
* Other sources not within the zonal network (MOA); Please list type of blood product

Prepared by:

____________________________________
Printed Name & Signature
Designation
OF BLOOD PRODUCTS DISPENSED

REPORTING MONTHS
TOTAL
%

TOTAL
%

TOTAL
%
FORM NO.: BM-08

Name of Hospital/PNRC Chapter:

Center for Health Development for: Qtr: Year:

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
Platelet Concentrate
Others:

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
Platelet Concentrate
Others:

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
Platelet Concentrate
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