DONOR SCREENING AND REGISTRATION CARD ‘STATE BLOOD TRANSFUSION COUNCIL, WEST BENGAL (Formatted as per guidelines of National Blood Policy) Name of Blood Bank Address ... License No. Unit Number Date of [Segment Number | Type of Bag ‘Signature of Blood Bank Staff Collection IName (capital letter)... 3 Age Male/Female lOccupation Father/Husband/Guardian's name 5 |Address, smrimmenines PhON@ NO. (O/RIM) Number of previous Donations. Date of Last Donation Blood Group, it detered previous (Reason or dear) oS So Se eee cae (ieee MO Earle redreeolraiant Do you feel well today? Le Dilsou weep ed orga Ge aren elses 1 onaiod blood before, dd you exparnce ay csconfor? fev il oe Gea taal aor Peace ep acer em pe as Gedy asian A STS IE O Antibiotics ©) Aspirin D Alcohol (12 hrs.) 0 Steroids 0) Vaccinations 0) Dog Bite / Rabies Vaccine (1 year.) [Bs you suter from or have satierd from any ofthe folowing dvtessT Tr Yoor USK tie soproorais POTTS] Cy ast Dla ing ieene gy Diesoe| Lt Caio hesnpony rea Epioy =] anual array ET Meeca ara ee Aig pee tea npe rered eyey a Peleg oO et Coppren Liste cares ames U rotuare Daseee D apaie teens reise eo Tt they a acta aie pee eae iol ve ar iiccpams ale uss ooeed ey bed mamma alee ual | sre Fc ats eal at ou ake ana vg oo areata Ei akc ener fe eave es oe mc cane Oil Ve ey Ts rae by sa hee Mic Tie ae oe seer }13. Persons who inject themselves with drugs, have multiple sex partners are lkely to be infected with virus causing AIDS. Do you practice any of the above? h« Geen og rere Rane toes OnE fy nea cy Usted Foes Cle) omnier ee axagariteiertaee ae we Re An seueehen ha (olen ogres es ec (Ce FF toe halal cr eoaas Remesc ea |18. Are you in lactating period? (Child less then 1 yr. old)? escra sctsant stay Fete coed u cereal fe cake onl tty ee Pols arenes ence es ee By als es corom ty ud Ean) sed asd Co goran aesranau lata Taare ay ses fe nada eal ee FAY aT AG os en ume ky Oo eT Seoe eo ee i eeael os le coc ane peice 3} Ipebik ern Paod UY fa eee Wy rey fo be Gokcosl eae) Risrrer oso FILE neat sero venus wou bas bs cea moe Donors ieradd Canter 120. | do hereby allow my blood for component separation and to use for plasma Fractination and Derivation of essential plasma derived| |medicines therefrom for the use of needy patients. i21. 1 do hereby agree to my Blood unit being utilised beyond the Blood Bank who is collecting my blood. = Mobile No. Land Phone No. . Signature / Thumb impression of the Donor Ts there any scars / Veni Punctures or skin disease a site of phlebotomy? o Yes Ne Weight... KG, PUISO sencnnnsnvnannnan FRR, BP Tmm hg, Temperature nen oF ‘CVS / Chest fit 7 unfit E Hb f ‘ial & Remarks poe Signature of M, O. / Doctor on TIME Phiebotomy Arm : Left / Right Reaction if any ; Remarks Signature of M.T. VolumeLex eee meee cae a, OFS TR A A. fa-ecn are (7) Fn cma en x aM Ew eee eacen wrt Paar wot wo PN ar Remar pe coc “ain Far ato ce eer CARAT? aie a 8 TAR CRIT? IC oR TF COTS OTR ET STAT aio Frareter, PET ACA CHCA BFR ACTOR A RR CATE SIE CRIA AAA CORT SHAT ARE ACATNA! (CORNEA) | Cetera Cait Cepacmen (23) Cotas Ceri Cgc ey / waren feat (> a2) [> [ER Fe cxmefirn cereal rwPDce BHT at ECICR? Catron CeHoTeR ORetreR Cree Cyt Comnis ORR One Octet tahoe Canmtare a) Cefn (fe sae) Oe B.S, Camera ore eaM) ORAS Cera are mC fence AHS ee CI CoAT EPR proare sor sett la aren corer Bit cron cater Fee AT = 30, a ee ARCH MAT CHAT TS RMT Fe AACR CRT HS MTN FT ss. stew ator eee, are pct a i dcores ate GLMTRR? 35. met reece Ca RC SN MOA, TMA, He F/O HET CR CAEN AES EAT Se CT CTT RARER THOT CITA FP re A ARCA TR, TH ROM EMT RTA CH, cata errs FageICR et sa few wie aia fa alate waula cereal aa ecafeer Gal wc Wie Bea (7) FH) Cae eestor AIA) CDSEO Co) ene CO) warTERC (6) se Cr [equa stereo] se. eet Ferg bu eo Fe ar re 3m STENT? ba wef fears eames sore wAtCRTE? py. et eet gene Ir (aor TOU 9 WORTH?) fore sr were CH a et ae a OM | TT x Ce MT Ie ERT LIC [erate ra ener waft a: sa.) Betcen oven extant ett rent ere Ab SEF 2 cee RT | Hee RT a RE CIC TR MAT AT SATU TOA IGT 0) STREET Aes. ARE, CeRABATR PY, FFE. a et, TMT 6 NAT A HT, ROSNER S| 1) orerncrre 4 eet eaCe TA ALL ©) STATE 6 aT wera wRICR OrORT CHER eT ara eng BL Fer et FR 1) aR ea eats AR em CN PR IEA AEN CRC TO. s0.stfrersxe Sra fee (Component Separation, errr (Plata) A ee ee SS A TATA | 3. cere ce cae oR TS IT RIGS SS CE CATH INA Ae IC MITA EE BEL Great aa Tatar aI AAT TORE oar oar le ls le. fs. eporere area gare