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    Report Forms (NBS) QUARTERLY FINAL

    Uploaded by

    Arvin Delos Santos
    The document contains donor recruitment and blood screening reports for a hospital/PRC chapter for three months (January, February, March). All data fields for the three months are blank or show errors, indicating no donors were recruited or blood was screened/tested. The reports track numbers of donors by recruitment type (voluntary, replacement, patient-directed) and reason for deferral or acceptance. They also report laboratory screening results for five diseases (HBV, syphilis, malaria, HIV, HCV) on blood units, including infection and rejection rates.

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    Report Forms (NBS) QUARTERLY FINAL

    Uploaded by

    Arvin Delos Santos
    2 views10 pages
    The document contains donor recruitment and blood screening reports for a hospital/PRC chapter for three months (January, February, March). All data fields for the three months are blank or show errors, indicating no donors were recruited or blood was screened/tested. The reports track numbers of donors by recruitment type (voluntary, replacement, patient-directed) and reason for deferral or acceptance. They also report laboratory screening results for five diseases (HBV, syphilis, malaria, HIV, HCV) on blood units, including infection and rejection rates.

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    Original Title

    Report Forms (NBS) QUARTERLY FINAL (1)

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    The document contains donor recruitment and blood screening reports for a hospital/PRC chapter for three months (January, February, March). All data fields for the three months are blank or show errors, indicating no donors were recruited or blood was screened/tested. The reports track numbers of donors by recruitment type (voluntary, replacement, patient-directed) and reason for deferral or acceptance. They also report laboratory screening results for five diseases (HBV, syphilis, malaria, HIV, HCV) on blood units, including infection and rejection rates.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    2 views10 pages

    Report Forms (NBS) QUARTERLY FINAL

    Uploaded by

    Arvin Delos Santos
    The document contains donor recruitment and blood screening reports for a hospital/PRC chapter for three months (January, February, March). All data fields for the three months are blank or show errors, indicating no donors were recruited or blood was screened/tested. The reports track numbers of donors by recruitment type (voluntary, replacement, patient-directed) and reason for deferral or acceptance. They also report laboratory screening results for five diseases (HBV, syphilis, malaria, HIV, HCV) on blood units, including infection and rejection rates.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    of 10

    FORM NO.

    : BM-01
    Name of Hospital/PRC Chapter:
    Center for Health Development for: Qtr: Year:

    TITLE : DONOR RECRUITMENT REPORT WITHOUT PRE-DONATION TESTING

    Form BM-01 A

    Deferred by History &


    Month P.E. Abnormal Hgb Other Reasons* Accepted
    Total No. of
    Donors No. % No. % No. % No. %
    January #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    February #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    March #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    TOTAL 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    Month January February March 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 Infectious Diseases
    Month Donors Deferred by History & PE Abnormal Hgb (TTDs) Other Reasons* Accepted and Bled
    No. % No. % No. % No. % No. %
    January #DIV/0! #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    February #DIV/0! #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    March #DIV/0! #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    TOTAL 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    Month January February March Total


    Other Reasons* No. % No. % No. % No. %

    Prepared by:

    ____________________________________
    Printed Name & Signature
    Designation
    FORM NO.: BM-02 Revised (for PRC use only)

    Name of PRC BSF:


    Center for Health Development for: Qtr: Year : 0

    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
    Donors No. % No. % No. % No. % No. % No. %
    January 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
    February 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
    March 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
    TOTAL 0 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    Remarks: Include Mass Blood Donations (MBD) under Voluntary
    FORM NO.: BM-03 A

    Name of Hospital/PRC 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 : January


    Seroprevalence
    Disease IR RR Lab. Error Accuracy PPV (To date)**
    No. of Blood Sero-
    Units Tested * No. % No. % % % % prevalence No. Tested %
    HBV #DIV/0! #DIV/0! #DIV/0!
    Syphilis #DIV/0! #DIV/0! #DIV/0!
    Malaria #DIV/0! #DIV/0! #DIV/0!
    HIV #DIV/0! #DIV/0! #DIV/0!
    HCV #DIV/0! #DIV/0! #DIV/0!

    Summary for the Month of : February


    Seroprevalence
    Disease IR RR Lab. Error Accuracy PPV (To date)**
    No. of Blood Sero-
    Units Tested * No. % No. % % % % prevalence No. Tested %
    HBV #DIV/0! #DIV/0! #DIV/0!
    Syphilis #DIV/0! #DIV/0! #DIV/0!
    Malaria #DIV/0! #DIV/0! #DIV/0!
    HIV #DIV/0! #DIV/0! #DIV/0!
    HCV #DIV/0! #DIV/0! #DIV/0!

    Summary for the Month of : March


    Seroprevalence
    Disease IR RR Lab. Error Accuracy PPV (To date)**
    No. of Blood Sero-
    Units Tested * No. % No. % % % % prevalence No. Tested %
    HBV #DIV/0! #DIV/0! #DIV/0!
    Syphilis #DIV/0! #DIV/0! #DIV/0!
    Malaria #DIV/0! #DIV/0! #DIV/0!
    HIV #DIV/0! #DIV/0! #DIV/0!
    HCV #DIV/0! #DIV/0! #DIV/0!

    * 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- Revised (for PRC use only)

    Name of PRC BSF:


    Center for Health Development for: Qtr: Year:

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


    FROM OUTSIDE SOURCES (Transfusion Transmitted Diseases Screening)

    Summary for the Month of : January


    Seroprevalence
    Disease IR RR Lab. Error Accuracy PPV (To date)**
    No. of Blood Sero-
    Units Tested * No. % No. % % % % prevalence No. Tested %
    HBV #DIV/0! #DIV/0! #DIV/0!
    Syphilis #DIV/0! #DIV/0! #DIV/0!
    Malaria #DIV/0! #DIV/0! #DIV/0!
    HIV #DIV/0! #DIV/0! #DIV/0!
    HCV #DIV/0! #DIV/0! #DIV/0!

    Summary for the Month of : February


    Seroprevalence
    Disease IR RR Lab. Error Accuracy PPV (To date)**
    No. of Blood Sero-
    Units Tested * No. % No. % % % % prevalence No. Tested %
    HBV #DIV/0! #DIV/0! #DIV/0!
    Syphilis #DIV/0! #DIV/0! #DIV/0!
    Malaria #DIV/0! #DIV/0! #DIV/0!
    HIV #DIV/0! #DIV/0! #DIV/0!
    HCV #DIV/0! #DIV/0! #DIV/0!

    Summary for the Month of : March


    Seroprevalence
    Disease IR RR Lab. Error Accuracy PPV (To date)**
    No. of Blood Sero-
    Units Tested * No. % No. % % % % prevalence No. Tested %
    HBV #DIV/0! #DIV/0! #DIV/0!
    Syphilis #DIV/0! #DIV/0! #DIV/0!
    Malaria #DIV/0! #DIV/0! #DIV/0!
    HIV #DIV/0! #DIV/0! #DIV/0!
    HCV #DIV/0! #DIV/0! #DIV/0!

    * 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-05A

    Name of Hospital/PRC Chapter:


    Center for Health Development for: Qtr: YEAR:

    TITLE : BLOOD DONATIONS DOCUMENTATION REPORT

    SOURCES REPORTING MONTHS


    Mass Blood January February March TOTAL
    Donations No. % No. % No. % No. %
    O+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    A+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    B+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    AB+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    Others
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    Walk-in Voluntary January February March TOTAL


    Blood Donations No. % No. % No. % No. %
    O+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    A+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    B+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    AB+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    Others
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    In-House January February March TOTAL


    Donations No. % No. % No. % No. %
    O+ 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    A+ 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    B+ 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    AB+ 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    Others
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    Replacement January February March TOTAL


    No. % No. % No. % No. %
    O+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    A+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    B+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    AB+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    Others
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    PATIENT- January February March TOTAL


    DIRECTED No. % No. % No. % No. %
    O+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    A+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    B+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    AB+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    0-
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    RC 143 or BRGY BASED January February March TOTAL


    No. % No. % No. % No. %
    O+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    A+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    B+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    AB+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    0-
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    Pledge 25 January February March TOTAL


    No. % No. % No. % No. %
    O+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    A+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    B+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    AB+ #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    0-
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    GRAND TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    Prepared by:
    ____________________________________
    Printed Name & Signature
    Designation
    FORM NO.: BM-06 - Revised (for PRC Use Only)

    Name of PRC BSF:


    Center for Health Development for: Qtr: Year:

    TITLE : INVENTORY OF BLOOD RECEIVED

    SOURCES REPORTING MONTHS


    January February March TOTAL
    No. % No. % No. % No. %
    Convalescent Plasma - Conventional
    Convalescent Plasma - Apheresis
    Apheresis - Platelet
    Apheresis - Frozen Plasma
    Packed Red Blood Cell
    Packed Red Blood Cell - LR
    Fresh Frozen Plasma
    Fresh Frozen Plasma- LR
    Cryoprecipitate
    Platelet Concentrate
    Platelet Concentrate- LR
    Cryosupernate
    Whole Blood #DIV/0! #DIV/0! #DIV/0! 0 #DIV/0!
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    April May June TOTAL


    Convalescent Plasma - Conventional
    Convalescent Plasma - Apheresis
    Apheresis - Platelet
    Apheresis - Frozen Plasma
    Packed Red Blood Cell
    Packed Red Blood Cell - LR
    Fresh Frozen Plasma
    Fresh Frozen Plasma- LR
    Cryoprecipitate
    Platelet Concentrate
    Platelet Concentrate- LR
    Cryosupernate
    Whole Blood #DIV/0! #DIV/0! #DIV/0! #DIV/0!
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!

    July August September TOTAL


    Convalescent Plasma - Conventional
    Convalescent Plasma - Apheresis
    Apheresis - Platelet
    Apheresis - Frozen Plasma
    Packed Red Blood Cell
    Packed Red Blood Cell - LR
    Fresh Frozen Plasma
    Fresh Frozen Plasma- LR
    Cryoprecipitate
    Platelet Concentrate
    Platelet Concentrate- LR
    Cryosupernate
    Whole Blood #DIV/0! #DIV/0! #DIV/0! #DIV/0!
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    October November December TOTAL
    Convalescent Plasma - Conventional
    Convalescent Plasma - Apheresis
    Apheresis - Platelet
    Apheresis - Frozen Plasma
    Packed Red Blood Cell
    Packed Red Blood Cell - LR
    Fresh Frozen Plasma
    Fresh Frozen Plasma- LR
    Cryoprecipitate
    Platelet Concentrate
    Platelet Concentrate- LR
    Cryosupernate
    Whole Blood #DIV/0! #DIV/0! #DIV/0! #DIV/0!
    SUB-TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!
    Other Sources * TOTAL

    SUB-TOTAL

    GRAND TOTAL 0 #DIV/0! 0 #DIV/0! 0 #DIV/0! 0 #DIV/0!


    * Other sources -A19 Please list type of blood product

    Prepared by:

    ____________________________________
    Printed Name & Signature
    Designation
    FORM NO.: BM-08

    Name of Hospital/PRC Chapter:


    Center for Health Development for: Qtr: Year:

    TITLE : BLOOD INVENTORY CONTROL REPORT

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


    January Balance from Dispensed Outdated Others ** Balance
    Product PreviousMonth Prepared Received No. % No. %
    Whole Blood #DIV/0! #DIV/0! 0
    Packed RBC #DIV/0! #DIV/0! 0
    Packed RBC - LR #DIV/0! #DIV/0! 0
    Fresh Frozen Plasma #DIV/0! #DIV/0! 0
    Fresh Frozen Plasma - LR #DIV/0! #DIV/0! 0
    Cryoprecipitate #DIV/0! #DIV/0! 0
    Cryosupernate #DIV/0! #DIV/0! 0
    Platelet Concentrate #DIV/0! #DIV/0! 0
    Platelet Concentrate - LR #DIV/0! #DIV/0! 0
    Apheresis - Platelet #DIV/0! #DIV/0! 0
    Apheresis - Frozen Plasma #DIV/0! #DIV/0! 0
    Convalescent Plasma - Conventional #DIV/0! #DIV/0! 0
    Convalescent Plasma - Apheresis #DIV/0! #DIV/0! 0
    Others: #DIV/0! #DIV/0! 0
    0
    350 0

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


    February Balance from Dispensed Outdated Others ** Balance
    Product PreviousMonth Prepared Received No. % No. %
    Whole Blood #DIV/0! #DIV/0! 0
    Packed RBC #DIV/0! #DIV/0! 0
    Packed RBC - LR #DIV/0! #DIV/0! 0
    Fresh Frozen Plasma #DIV/0! #DIV/0! 0
    Fresh Frozen Plasma - LR #DIV/0! #DIV/0! 0
    Cryoprecipitate #DIV/0! #DIV/0! 0
    Cryosupernate #DIV/0! #DIV/0! 0
    Platelet Concentrate #DIV/0! #DIV/0! 0
    Platelet Concentrate - LR #DIV/0! #DIV/0! 0
    Apheresis - Platelet #DIV/0! #DIV/0! 0
    Apheresis - Frozen Plasma #DIV/0! #DIV/0! 0
    Convalescent Plasma - Conventional #DIV/0! #DIV/0! 0
    Convalescent Plasma - Apheresis #DIV/0! #DIV/0! 0
    Others: #DIV/0! #DIV/0! 0

    350 0 0

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


    March Balance from Dispensed Outdated Others ** Balance
    Product PreviousMonth Prepared Received No. % No. %
    Whole Blood #DIV/0! #DIV/0! 0
    Packed RBC #DIV/0! #DIV/0! 0
    Packed RBC - LR #DIV/0! #DIV/0! 0
    Fresh Frozen Plasma #DIV/0! #DIV/0! 0
    Fresh Frozen Plasma - LR #DIV/0! #DIV/0! 0
    Cryoprecipitate #DIV/0! #DIV/0! 0
    Cryosupernate #DIV/0! #DIV/0! 0
    Platelet Concentrate #DIV/0! #DIV/0! 0
    Platelet Concentrate - LR #DIV/0! #DIV/0! 0
    Apheresis - Platelet #DIV/0! #DIV/0! 0
    Apheresis - Frozen Plasma #DIV/0! #DIV/0! 0
    Convalescent Plasma - Conventional #DIV/0! #DIV/0! 0
    Convalescent Plasma - Apheresis #DIV/0! #DIV/0! 0
    Others: #DIV/0! #DIV/0! 0

    350 0 0
    * Put an asterisk if processing done outside BSF
    ** Others also include punctured blood units, hemolyzed, wastage, etc….

    Prepared by:

    ____________________________________
    Printed Name & Signature
    Designation

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