FORM NO.

: BM-01

Name of Hospital/PNRC Chapter:

Quarter: Year:

TITLE: DONOR RECRUITMENT REPORT WITHOUT PRE- DONATION TESTING

Form BM-01 A

Deferred by Lab. Testing

Total No. of Deferred by History Infectious Other Reasons* Accepted
MONTH
Donors &PE Abnormal Hgb Diseases(TTDs)
No. % No. % No. % No. % No. %

TOTAL

MONTH Total
Other Reasons* No. % No. % No. % No. %
 TITLE: DONOR RECRUITMENT REPORT WITH PRE- DONATION TESTING

Form BM-01 B

Deferred by History Deferred by Lab. Testing

Infectious
Total No. of Other Reasons* Accepted
MONTH &PE Abnormal Hgb Diseases(TTDs)
Donors
No. % No. % No. % No. % No. %

TOTAL

MONTH Total
Other Reasons* No. % No. % No. % No. %

Prepared by:

Printed Name & Signature

Designation
FORM NO.: BM-02

Name of Hospital/PNRC Chapter:

Quarter: Year:

TITLE: CLASSIFICATION OF ACCEPTED BLOOD DONORS

INDICATORS
Total No. VOLUNTARY REPLACEMENT PATIENT - DIRECTED
Month
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:

Quarter: Year:

TITLE: LABORATORY REPORT FORM FOR DONORS RECRUITED IN BSF ONLY

(Transfusion Transmitted Diseases Screening)

Summary for the Month of:

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

Summary for the Month of:

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

Summary for the Month of:

No. of Units IR RR Lab. Error Accuracy PPV Seroprevalence (to date)**
Disease Seroprevalence
Blood Tested* No. % No. % % % % 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
FORM NO.: BM-03 B

Name of Hospital/PNRC Chapter: SALUG VALLEY MEDICAL CENTER

Quarter: 1ST Year: 2021

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

(Transfusion Transmitted Diseases Screening)

Summary for the Month of:

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

Summary for the Month of:

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

Summary for the Month of:

Units
Blood IR RR Lab. Error Accuracy PPV Seroprevalence (to date)**
Disease Seroprevalence
Tested* No. % No. % % % % 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
FORM NO.: BM-04

Name of Hospital/PNRC Chapter: SALUG VALLEY MEDICAL CENTER

Quarter: 2ND Year: 2021

TITLE: BLOOD USAGE MONITORING REPORT

Crossmatched*/Transfused Ratio
Blood and Blood Products No. of units REQUESTED No. of Units No. of Units C/T Ratio
CROSSMATCHED TRANSFUSED
MONTH: APRIL
Whole Blood (WB) 1 1 1 1
Packed Red Blood Cells(PRBC) 2 2 2 2
Fresh Frozen Plasma (FFP) 0 0 0 0
Cryosupernate(CryoS) 0 0 0 0
Cryoprecipitate(CryoP) 0 0 0 0
Platelet Concentrate (Pltcon) 0 0 0 0
Others (specify):

Blood and Blood Products No. of units REQUESTED No. of Units No. of Units C/T Ratio
CROSSMATCHED TRANSFUSED
MONTH: MAY
Whole Blood (WB) 0 0 0 0
Packed Red Blood Cells(PRBC) 0 0 0 0
Fresh Frozen Plasma (FFP) 0 0 0 0
Cryosupernate(CryoS) 0 0 0 0
Cryoprecipitate(CryoP) 0 0 0 0
Platelet Concentrate (Pltcon) 0 0 0 0
Others (specify):

Blood and Blood Products No. of units REQUESTED No. of Units No. of Units C/T Ratio
CROSSMATCHED TRANSFUSED
MONTH: JUNE
Whole Blood (WB) 0 0 0 0
Packed Red Blood Cells(PRBC) 1 1 1 1
Fresh Frozen Plasma (FFP) 0 0 0 0
Cryosupernate(CryoS) 0 0 0 0
Cryoprecipitate(CryoP) 0 0 0 0
Platelet Concentrate (Pltcon) 0 0 0 0
Others (specify):

Prepared by:

Sheehanne Erl B. Noval,RMT

Chief Medical Technologist
FORM NO.: BM-05A

Name of Hospital/PNRC Chapter: SALUG VALLEY MEDICAL CENTER

Quarter: 1ST Year: 2021

TITLE: BLOOD DONATIONS DOCUMENTATION REPORT (SCREENED/TESTED)

SOURCES REPORTINGS MONTHS

APRIL MAY JUNE Total
Mass Blood Donations
No. % No. % No. % No. %
O+ 0 0
A+ 0 0
B+ 0 0
AB+ 0 0
Others 0 0
SUB-TOTAL 0 0

APRIL MAY JUNE Total

Walk-in Voluntary Blood Donations
No. % No. % No. % No. %
O+ 0 0
A+ 0 0
B+ 0 0
AB+ 0 0
Others 0 0
SUB-TOTAL 0 0
APRIL MAY JUNE Total
In-House Donations
No. % No. % No. % No. %
O+ 0 0
A+ 0 0
B+ 0 0
AB+ 0 0
Others 0 0
SUB-TOTAL 0 0
APRIL MAY JUNE Total
Replacement
No. % No. % No. % No. %
O+ 0 0
A+ 0 0
B+ 0 0
AB+ 0 0
Others 0 0
SUB-TOTAL 0 0
GRAND TOTAL: 0 0

Prepared by:

Printed Name & Signature

Designation
FORM NO.: BM-05B

Name of Hospital/PNRC Chapter: SALUG VALLEY MEDICAL CENTER

Quarter: 2ND Year: 2021

TITLE: BLOOD DONATIONS DOCUMENTATION REPORT (For patient Directed and Autologous Donations)

SOURCES REPORTINGS MONTHS

APRIL MAY JUNE Total
DIRECTED DONATIONS
No. % No. % No. % No. %
O+ 0 0
A+ 0 0
B+ 0 0
AB+ 0 0
Others 0 0
SUB-TOTAL 0 0

APRIL MAY JUNE Total

AUTOLOGOUS DONATIONS
No. % No. % No. % No. %
O+ 0 0
A+ 0 0
B+ 0 0
AB+ 0 0
Others 0 0
SUB-TOTAL 0 0
GRAND TOTAL 0 0

Prepared by:

Printed Name & Signature

Designation
FORM NO.: BM-06

Name of Hospital/PNRC Chapter: SALUG VALLEY MEDICAL CENTER

Quarter: 2nd Year: 2021

TITLE: INVENTORY OF BLOOD RECEIVED

SOURCES REPORTING MONTHS

APRIL MAY JUNE Total
LEAD BLOOD SERVICE FACILITY (BSF) No. % No. % No. % No. %
Packed Red Blood Cell 0 0 0 0 0 0 0
Fresh Frozen Plasma 0 0 0 0 0 0 0 0
Cryoprecipitate 0 0 0 0 0 0 0 0
Platelet Concentrate 0 0 0 0 0 0 0 0
Cryosupernate 0 0 0 0 0 0 0 0
Whole Blood 0 0 0 0 0 0 0 0
Sub-Total 0 0 0 0 0 0 0 0
APRIL MAY JUNE Total
SATELITTE BSF
No. % No. % No. % No. %
Packed Red Blood Cell 0 0 0 0 0 0 0 0
Fresh Frozen Plasma 0 0 0 0 0 0 0 0
Cryoprecipitate 0 0 0 0 0 0 0 0
Platelet Concentrate 0 0 0 0 0 0 0 0
Cryosupernate 0 0 0 0 0 0 0 0
Whole Blood 0 0 0 0 0 0 0 0
Sub-Total 0 0 0 0 0 0 0 0
APRIL MAY JUNE Total
PNRC
No. % No. % No. % No. %
Packed Red Blood Cell 0 0 0 0 0 0 0 0
Fresh Frozen Plasma 0 0 0 0 0 0 0 0
Cryoprecipitate 0 0 0 0 0 0 0 0
Platelet Concentrate 0 0 0 0 0 0 0 0
Cryosupernate 0 0 0 0 0 0 0 0
Whole Blood 1 100 0 0 0 0 1 25
Sub-Total 1 100 0 0 0 0 1 25

APRIL MAY JUNE Total

COMMERCIAL BLOOD BANK
No. % No. % No. % No. %
Packed Red Blood Cell 0 0 0 0 0 0 0 0
Fresh Frozen Plasma 0 0 0 0 0 0 0 0
Cryoprecipitate 0 0 0 0 0 0 0 0
Platelet Concentrate 0 0 0 0 0 0 0 0
Cryosupernate 0 0 0 0 0 0 0 0
Whole Blood 0 0 0 0 0 0 0 0
Sub-Total 0 0 0 0 0 0 0 0
APRIL MAY JUNE Total
Other Sources: MHARS-MC
No. % No. % No. % No. %
Packed Red Blood Cell 2 100 0 0 1 100 3 75

SUB TOTAL 2 100 0 0 1 100 3 75

GRAND TOTAL 3 75 0 0 1 25 4 100
* Other sources not within the zonal network (MOA) please list type of blood product

Prepared by:

SHEEHANNE ERL B. NOVAL, RMT

Chief Medical Technologist
FORM NO.: BM-07

Name of Hospital/PNRC Chapter:

Quarter: Year:

TITLE: INVENTORY OF BLOOD DISPENSED

RECIPIENT INSTITUTION REPORTING MONTHS

SATELLITE BSF within the Zonal APRIL MAY JUNE

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

APRIL MAY JUNE

OTHER HOSPITALS* outside the
Zonal Network (MOA) 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)
APRIL MAY JUNE
IN-HOUSE
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 products
Prepared by:

Printed Name & Signature

Designation
 Total
No. %

Total
No. %

Total
No. %
FORM NO.: BM-08

Name of Hospital/PNRC Chapter: SALUG VALLEY MEDICAL CENTER

Quarter: 2ND Year: 2021

TITLE: BLOOD INVENTORY CONTROL REPORT

MONTH: APRIL Total No. of Units Unused units

No. of units
Balance from Outdated Others ** Ending Balance
Prepared Received Dispensed
Product Previous Month No. % No. %
Whole Blood 0 0 1 1 0 0 0 0 0
Packed RBC 0 0 2 2 0 0 0 0 0
Fresh Frozen Plasma 0 0 0 0 0 0 0 0 0
Cryoprecipitate 0 0 0 0 0 0 0 0 0
Cryosupernate 0 0 0 0 0 0 0 0 0
Platelet Concentrate 0 0 0 0 0 0 0 0 0
Others: 0 0 0 0 0 0 0 0 0

MONTH: MAY Total No. of Units Unused units

No. of units
Balance from Outdated Others ** Ending Balance
Prepared Received Dispensed
Product Previous Month No. % No. %
Whole Blood 0 0 0 0 0 0 0 0 0
Packed RBC 0 0 0 0 0 0 0 0 0
Fresh Frozen Plasma 0 0 0 0 0 0 0 0 0
Cryoprecipitate 0 0 0 0 0 0 0 0 0
Cryosupernate 0 0 0 0 0 0 0 0 0
Platelet Concentrate 0 0 0 0 0 0 0 0 0
Others: 0 0 0 0 0 0 0 0 0
MONTH: JUNE Total No. of Units Unused units
No. of units
Balance from Outdated Others ** Ending Balance
Prepared Received Dispensed
Product Previous Month No. % No. %
Whole Blood 0 0 0 0 0 0 0 0 0
Packed RBC 0 0 1 1 0 0 0 0 0
Fresh Frozen Plasma 0 0 0 0 0 0 0 0 0
Cryoprecipitate 0 0 0 0 0 0 0 0 0
Cryosupernate 0 0 0 0 0 0 0 0 0
Platelet Concentrate 0 0 0 0 0 0 0 0 0
Others: 0 0 0 0 0 0 0 0 0

* Put an asterisk if processing done outside BSF

** Others also include punctures blood units, hemolyzed, wastage, etc….

Prepared by:
Sheehanne Erl B. Noval, RMT
Chief Medical Technologist