Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

DEC 23 201
ADMINISTRATIVE ORDER
No. 2021 - _0066

SUBJECT: Guidelines on the Issuance of Certificate of Inclusion (COX) in the

Blood Services Network (BSN)

BACKGROUND

Pursuant to Section 2. Declaration of Policy of the Republic Act (RA) No. 7719
entitled “National Blood Services Act of 1994”, the Department of Health (DOH) is
mandated to establish and organize a National Blood Transfusion Services Network to
rationalize and improve the provision of adequate and safe supply of blood and blood
products.

Blood Centers (BCs) and other Blood Service Facilities (BSFs) nationwide are
organized into Blood Services Networks (BSNs), wherein each is designed to adapt to
the unique situation of their localities adhering to the existing standards of the National
Voluntary Blood Services Program (NVBSP). The NVBSP in line with the provisions
of RA No. 11223 or the “Universal Health Care (UHC) Act” and its Implementing
Rules and Regulations (IRR), aims to ensure equitable access to safe and quality blood
and blood products, and efficient blood service delivery to province-wide and city-wide
health systems (P/CWHS) by effective regulation of BSNs.

The Certificate of Inclusion (COI) is a requirement prior to the issuance of the

DOH - License to Operate (DOH-LTO) to BSFs pursuant to Administrative Order No.
2008-0008 or the “Rules and Regulations Governing the Regulation of BSFs”.

To attain an efficient and effective BSN that will provide timely access to safe
blood and blood products, all BSFs shall secure the required COI. Hence, this policy
shall provide the guidelines for the issuance of COI to
all BSFs in the country.

IL OBJECTIVES

This Order aims to provide the revised guidelines on the issuance of COI to
ensure adequate and accessible supply of safe blood and blood products within their
geographical area, and that all BSFs included in the BSN are continuously compliant
with the COI requirements and all other related policies, guidelines, and standards set

J
by the DOH.

Building 1, San Lazaro Compound, Rizal Avenue, Sta. Cruz, 1003 Manila e Trunk Line 8651-7800 local 1108, 1111, 1112, 1113
Direct Line: 8711-9502; 8711-9503 Fax: 8743-1829 & URL: htip://www.doh.gov.ph; e-mail: fiduque@doh.gov.ph
b
IIL SCOPE OF APPLICATION

This Order shall apply to all publicly and privately-owned BSFs as well as end-
user non-hospital based health facilities.

Iv. DEFINITION OF TERMS

A. Blood Services Network (BSN) — refers to an organization established to provide

for the blood needs of a specific geographical area or catchment population. It is
composed of the designated blood center, hospital blood banks, blood collection
units, blood stations, and end-user non-hospital based health facilities. The
objective of the BSN is to ensure the efficient distribution of voluntarily donated
blood from blood center to different BSFs, hospitals, and other end-users to make
blood available to all patients, maximize utilization of available blood, and avoid
wastage.

Certificate of Inclusion (COI) — refers to an official document attesting that the

BSF belongs to a BSN, compliant to the policies, guidelines, and standards set by
the DOH NVBSP, and actively participating in the provision of efficient blood
services by ensuring delivery of safe, adequate, and accessible blood supply.

DOH Center for Health Development (DOH CHD) - Regional Voluntary Blood
Services Program (RVBSP) — refers to the regional counterpart or field
representative of NVBSP in the CHDs in implementing the Program’s policies,
coordination of core activities such as promotion of voluntary blood donation,
public education and advocacy, rationalization of BSFs with functional BSN, and
effective and equitable collection and distribution of blood and other resources.

DOH - License to Operate (DOH-LTO) — refers to a formal authority issued by

the DOH to an individual, agency, partnership, or corporation to operate a BSF or
other health facility.

End-user non-hospital based hemodialysis clinic — refers to a DOH licensed non-

hospital based health facility which may administer blood transfusion to their
patients.

Hospital Blood Bank with additional functions (HBB+) — refers to a DOH

licensed BSF within the premises of a hospital with service capabilities of a hospital
blood bank as defined in AO No. 2008-0008 and is allowed to perform the following
additional procedures: a) blood collection from volunteer blood donors, b) blood
testing using the NVBSP recommended methodologies, and c) processing of blood
components.

. Hospital Blood Transfusion Committee (HBTC) — refers to a hospital committee

primarily responsible for the formulation of blood bank and blood transfusion
policies and guidelines for monitoring and audit of the use of blood and blood
components within the facility, provided that they are in accordance with the latest
Manual of Standards for BSF issued by the DOH.

dw) 2
H. Lead Blood Service Facility (LBSF) — refers to a hospital or non-hospital based
BSF designated by NVBSP within the BSN. They may be Blood Centers (BCs) and
Hospital Blood Banks (HBBs) that are authorized to collect, test, and process blood
in the region or zone. The lead BSF oversees the satellite BSF within its zone.

I. National Blood Bank Network System (NBBNetS) —refers to an online system

where BSFs can directly enter data or upload data on blood collection, processing,
testing, dispensing, and utilization.

J. Satellite BSF — refers to a blood service facility that is a member of a zonal BSN
and is monitored by the LBSF.

GENERAL GUIDELINES

A. All BSFs from the zonal BSN shall secure a COI as a prerequisite for the issuance
of DOH-LTO.

B. The application process shall be aided by the use of a checklist that follows the
utilization and implementation of the NVBSP Manual of Standards:
1. Manual of Standards for BSFs
2. Manual on Donor Recruitment and Counselling
3. Philippine Clinical Practice Guidelines (CPGs) for the Rational Use of Blood
and Blood Products and Strategies for Implementation

C. In case that the assessment of both the LBSF and the Regional Blood Program
Coordinator (RBPC) results in the downgrading of the blood service category of the
applicant BSF, the procedure for Renewal of COI shall be followed.

D. For inter-regional or inter-zonal BSN, assessment of compliance shall be done by

the LBSF where the satellite BSF was networked using the same Checklist of
Application of COI. However, issuance of the COI shall be from their respective
DOH Center for Health Development (CHD).

E. The overall processing of COI shall be done by the DOH CHD in coordination with
the LBSF. The processing time for the issuance of COI application shall be twenty
(20) working days upon receipt of complete documentary requirements.

F. The validity period of the COI shall be synchronized with the validity period of
their LTO (January to December of the following year). Application for issuance of
COI shall start in the 3rd quarter of the year (July of the current year) to provide
ample time for the BSF to prepare the required documents, and for the LBSF to plan
the schedule for physical inspection.

G. All BSFs (hospital and non-hospital based) shall renew their COI annually. The
COl reference number shall be presented in the next renewal of DOH-LTO as proof
of compliance and participation in the network.

H. For end-user non-hospital based facilities such as Hemodialysis Clinics (HDC),

compatibility testing and cross-matching shall be performed in a hospital-based

dnt) 3

7
 clinical laboratory. One may enter a Memorandum of Agreement (MOA) as stated
in AO No. 2012-0001 entitled, “New Rules and Regulations Governing the
Licensure and Regulation of Dialysis Facilities in the Philippines.”

I. A functional and active HBTC is a prerequisite for the issuance of the COI,
licensing of a hospital by the DOH, and accreditation by the Philippine Health
Insurance Corporation (PhilHealth).

J. The DOH CHD shall issue the COI for the following BSFs that are fully compliant
to the requirements set by DOH NVBSP:

1. Participating members of the BSN within their region that are monitored by the
LBSF and RBPC using the monitoring tool checklist (Annexes B or C).

2. LBSFs that are monitored by the RBPC using the same checklist (Annex C)
based on existing monitoring schemes.

K. The DOH CHD shall submit to the DOH NVBSP the final list of BSFs issued with
COI (on or before September 01 of the current year). The DOH NVBSP shall
annually (on or before October 1 of the current year) consolidate and endorse the
final list of BSFs with their corresponding BSF category for COI to the DOH Health
Facilities and Services Regulatory Bureau (HFSRB).

VL SPECIFIC GUIDELINES

A. Initial Application of COI

1. The BSF shall submit a Letter of Intent (LOI) for application for COI addressed
to the DOH CHD Director, attention to the Regional Blood Program
Coordinator (RBPC).
2. The DOH CHD shall notify the applicant BSF for the designated LBSF and its
BSN.
3. The applicant BSF shall closely coordinate with the LBSF for the processing of
documentary requirements listed in Annex B: Requirements for Initial
Application of COL
4. The LBSF shall be responsible for the orientation of their zonal BSN about the
MOA provisions.
5. The LBSF shall check and assess the application documents (Annex B).
Incomplete application documents shall not be accepted or processed.

B. Upgrading of BSF category for COI

1. Any BSF may apply for an upgrade and shall follow steps in the initial
application and provide a copy of their recent DOH-LTO.
2. Upon the recommendation of the LBSF and the RBPC, the CHD Director shall
submit an assessment report and justification letter to DOH NVBSP for its
approval.

MY 4
 a. Once approved, DOH NVBSP shall submit a Letter of Approval to the DOH
CHD’s Regional Voluntary Blood Services Program (RVBSP).
b. DOH NVBSP shall provide a copy of the Letter of Approval to HFSRB.

C. Renewal of COI

1. The satellite BSF shall submit an LOI to the Head of the LBSF for the
recommendation of renewal of COI together with the requirements listed in
Annex C: Requirements for Renewal of Application.
2. The LBSF shall check and assess the application documents (Annex C).
Incomplete application documents shall not be accepted or processed.

D. Application of LBSF for COI

are initially designated according to the strategies and criteria set by

All LBSFs
the NVBSP based on the Department Memorandum (DM) No. 2016-0451 entitled
“Designation of Lead Blood Service Facilities” Thus, all LBSFs shall renew their COI
annually and shall be directly monitored by DOH CHD through the RBPC for its
compliance to standards and based on its functions.

1. The LBSF shall submit pertinent documents based on Annex C.

2. The LOI for renewal of COI shall then be addressed to the DOH CHD Director,
attention to the RBPC.
3. A signed copy of the MOA with the satellite BSF shall be submitted. The LBSF
shall submit the requirements prescribed in the provisions of the MOA (Item 4
of Annex C) together with the other remaining requirements stipulated in Annex
C.
The DOH CHD through the RBPCs shall check and assess the application
requirements (Annex C). Incomplete application requirements shall not be
accepted or processed by the DOH CHD.

E. Review of Compliance and Processing of Application

1. For initial application and renewal, review of compliance or assessment shall

be primarily done by the LBSF followed by the final review of the DOH CHD
whereas the application of LBSF shall be solely done by the DOH CHD through
the RBPC.
If the documentary requirements are complete, the NBBNetS requirements shall
be referred to NVBSP Information Management Unit (IMU) for verification.
The NBBNetS requirements shall be endorsed back to the LBSF or DOH CHD
once verified.
3. Non-compliant BSFs shall be notified and be given twenty (20) working days
as a grace period to comply. The grace period shall start upon receipt of their
notification.
4. The following steps will only apply to initial application and renewal for COI:
a. If the applicant BSF is compliant, the LBSF shall issue a recommendation
letter (Annex D) indicating the recommended BSF category for COI based
on the result of the assessment.

LA
 b. The LBSF shall submit the final list of the BSFs within the zonal BSN
together with the duly accomplished checklist on the Application of COI,
recommendation letter, and its supporting documents signed by the LBSF.
c. All documents to be endorsed shall be addressed to the CHD Regional
Director, attention to the RBPC. The LBSF shall be responsible for the
transmittal of documentary requirements to the DOH CHD.
Sn
Final review of documents shall be done by the RBPC.
The CHD Director shall issue COI upon recommendation of the RBPC.
Signatory of the COI in theBSN:
a. The certificate shall be initialed by the RBPC and approved by the CHD
Director
b. The standard template of the COI (Annex E) shall be issued by the DOH
CHD.
Once the COI is issued to the applicant BSF, the BSF shall be referred to as
satellite BSF.

VII. ROLES AND RESPONSIBILITIES

A. DOH - National Voluntary Blood Services Program (DOH NVBSP) -

Management Unit shall:
1. Oversee the implementation of the BSNs nationwide for the rationalization of
BSFs and to ensure the provision of adequate, accessible, and safe blood supply.
2. Consolidate and endorse to the HFSRB the final list of BSFs with their
corresponding BSF category for COIL
3. Approve the application for upgrade to BC and HBB+ upon the
recommendation from DOH CHD; and issue Letter of Approval to DOH CHD
and endorse the said Letter of Approval to HFSRB.

NVBSP - Information Management Unit (NVBSP-IMU), the system owner and

the Operation Center of NBBNetS, shall:
1. Produce donation ID stickers that shall be used to label the blood and blood
products. The donation ID stickers shall have an accession code that will be
linked to the NBBNetS.
Validate NBBNetS requirements submitted by the applicant, satellite, and lead
BSF.
Prepare a notification report that the applicant BSF has a letter of application
is
for subscription or any proof of proper use of donation ID stickers or actively
using the NBBNetS. The notification shall be sent through e-mail to the LBSF
or DOH CHD.
Facilitate subscription application of BSFs for the use of NBBNetS and provide
technical assistance and/or troubleshooting.

DOH Centers for Health Development (DOH CHD) shall:

1. Implement the regional BSN for the rationalization of BSFs and ensure the
provision of adequate, accessible, and safe blood supply in the region.
2. Issue the COI in the BSN (based on the guidelines set forth in this Order):
a. To the satellite BSFs upon recommendation of the LBSF.
b. To the designated LBSF
ifthey perform their functions as LBSF.
c. If the BSF complies with the requirements per BSF Category.

ary) o
1
 d. If the BSF utilized and implemented the NVBSP’s Manual of Standards.
3. Recommend to the DOH NVBSP the upgrading of BSF and application for BC
and HBB+ following the rationalization plan of BSF by the CHD.

D. Lead Blood Service Facilities (LBSFs) shall:

1. Review the documents of applicant BSFs and satellite BSFs in the initial
application or renewal of COL
2. Perform a physical site visit with the RBPC for the verification of the documents
submitted. The LBSF, in coordination with the RBPC, may conduct random site
visits (physical or virtual) to check the BSF’s compliance with the COI checklist
as necessary.
3. Recommend BSFs for issuance of COI based on the assessment conducted and
submit the list of BSFs to CHD Director, attention to the RBPC.
4. Monitor participation of satellite BSFs through their attendance in network
meetings and submission of reports.

VIIL REPEALING CLAUSE

This Order shall repeal DM No. 2016-0448 entitled “Guidelines on the Issuance
of Certificate of Inclusion to Blood Services Network”, dated14 December 2016 and
all other issuances inconsistent with this Order.

IX. SEPARABILITY CLAUSE

In the event that any provision or part of this Orderis

declared unauthorized or
rendered invalid by any court of law or competent authority, those provisions not
affected by such declaration shall remain valid and in force.

EFFECTIVITY

This Order shall take effect fifteen (15) days after its publication in the Official
Gazette or in any national newspaper of general circulation, with three (3) certified
copies to be filed with the Office of the National Administrative Register (ONAR) of
the University of the Philippines (UP) Law Center.
CC
ANNEX A. Process Flow on Initial Application of Certificate of Inclusion (20 Working Days)
INITIAL APPLICATION OF CERTIFICATE OF INCLUSION

Blood Service Facility (BSF) DOH - Center for Health Development (CHD) Lead Blood Service Facility (LBSF) NVBSP
- Information Management Unit j

stat
f

'
Verity NBBNetS appropriate use of
fi
|
Receipt and checking
" n

'
«
:
: donation 1D
for
i

Determine LBSF the of application or subscription based

on available docuren
applicant BSF and forward Documents
' information
Submission of
EY
Acceptance of copy of letter to LBSF i

Letter of intent Letter of Intent ‘

NO
Tequired documen \
Submission of '
complete?
V

Application |
Documents Notify applicant BSF i
|
i
where to process its '
' Thscription of NBENetS / proper
application V

of sticker verifiable?

Referral to NVBSP i

Assessment of IMU for NBBNetS

application
Documents 7

YES documents :

verification
i
i
i
‘
i
i
i
i
i Forward NBBNetS
i
Is compliance Notify BSF to submit \
subscription status and
received within 20 A compliance within 20 V
Application Documents for
working days? working days deliberation and
‘
appropriate action
)
i
i
i

i
i
i
\

'
|
Acceptance of i
Verify type of
Recommendation Letter and |

application
Application Documents i
i

l i

NO Final evaluation by RBPC

i
|

Submit i
i

recommendation i

and Application Is new and upgrading ? i

i

Document to i

DOH-CHD
i

Issuance of COI i
|

i
'
i

i
i
hh
ANNEX B. Process Flow on Upgrading of BSF Category (20 Working Days)
i
UPGRADING OF BSF CATEGORY FOR CERTIFICATE OF INCLUSION

[
DOH - Center for Health Development (CHD) DOH National Voluntary Blood Services Program Central Office

Provide recommendation and

justification for the new Is application approved?
application’ upgrade of BSF
category

NO
YES

Submit recommendation to Submit a letter of recommendation

Issuance of COI
retain current BSF Category to DOH CHO for the upgrading of
BSF Category of the applicant BSF
and copy fumished HFSRB

NOTE: All BSF with application for upgrading shall follow the steps in the initial application first.

SY
—s
ANNEX C. Process Flow on Renewal of Certificate of Inclusion

|
[
RENEWAL OF CERTIFICATE OF INCLUSION ]

|
]
Blood Service Facility (BSF) Lead Blood Service Facility (LBSF) | NVBSP- Information Management Unit DOH - Center for Health Development (CHD)
r
V

‘
Start : ‘
'
Verify NBBNetS
‘
'
'
:
appropriate use of ‘

; donation ID
or
:
subscription based on
Submission of Receipt and checking of : available documents! ’

Application application Documents : information Acceptance of

r™ Recommendation Letter and
Documents i

: Application Documents
:
NO i

}
GUhscription of NBENetS f proper use ‘
‘
‘
: sticker verifiable? i
i
'
Referral to NVBSP | i
'
Assessment of IMU for NBBNetS | \
'
applicati Documents '
torments |
Final evaluation by RBPC
verification +

YES : }

i
i
‘

: Forward NBENetS i
Notify BSF to submit ' subscription status and i

in p Aa
liance received
complian within 20 NO i

compliance within 20 Compliant? «————— Application Documents for i

working days?
working days deliberation and i
|

appropriate action i

YES i
‘

'

\
‘ A

v.
'
}

'
Submit recommendation and '
Application Document to Issuance of COI
DOH-CHD

'
'
'
'
i
‘

i
'

Co
i

Qo)
of
ANNEX D
Checklist on Initial Application of COI/ Upgrading of BSF Category for COI

Name of the BSF:

Level of the Facility (for Hospital-based BSF):
Current BSF Category:

Initial application with no request for upgrading J] Initial application with request for upgrading

Requirements
1 Check (/) if
complied

and
1. Letter of Intent addressed to the CHD Director, Attention: the RBPC

BC.
2. *Upon Verification of Category by the LBSF, submission of:
» Memorandum of Agreement with Lead BSF* OR
=
Memorandum of Agreement with Dialysis Clinic **
Recent copy of DOH-License To Operate (for initial application with request for upgrading)

BCU
=

P.1. The Memorandum of Agreement shall be region specific. However, the MOA shall have the following

Blood
provisions that the satellite BSF shall comply.*

2.1.1, Commitment to provide resources for Voluntary Blood Donation Activities for
HBB+

Manual
2.1.1.1. Total number of manpower involved in BSF based on category

Standards
a. List of dedicated personnel with designation

b. Job description with signed conforme

c. Copy of Contract of Service or appointment paper

for
2.1.1.2. Vehicle Availability

a. Photocopy of OR/CR of vehicle

2.1.1.3. Allotted budget for blood donation activities

a. Attach an operational plan or work and financial plan

2.1.1.4. List of appropriate equipment based on the

Service Facilities

2.1.2. Enforce BSN commitment to synchronized collection and distribution;

2.1.2.1 Catchment Area

a. List of Partners with MOA within the zonal BSN

2.1.2.2. Frequency of Mobile Blood Donation

a. Calendar of scheduled MBDs

2.1.2.3. Process flow from organizing blood donation, collection to distribution

2.1.2.4. Direct Distribution of Blood/Blood products

a. List of Blood Service Facilities within the zonal BSN

2.1.2.4. Network Meeting Attendance

2.1.3. A functional and active HBTC is a prerequisite for the issuance of the COI. HBTC minutes of the meeting with
pictures (for hospital-based only)

2.1.4. Patient billing statement reflecting fees for whole blood, packed red blood cells. platelet concentrate, and/or
fresh frozen plasma (Compliant to AO 2015-0043)
2.1.5. Weekly Blood Inventory Management Report
 ANNEX D
Checklist on Initial Application of COY/ Upgrading of BSF Category for COI

2.1.6. Use of the NVBSP prescribed Blood Request Form for Adult and Pediatrics (Hospital-based only) for
appropriate indication for transfusion as stated in the Philippine Clinical Practice Guidelines for the Rational
Use of Blood and Blood Products and Strategies for Implementation

2.1.7. Letter of application for subscription to NBBNetS or proof ofappropriate use of Donation ID sticker

2.2. Memorandum of Agreement (MOA) with Dialysis Clinic (free-standing or hospital-based dialysis center not
owned by the hospital) as end user**

2.2.1. Patient billing statement reflecting fees for whole blood, packed red blood cells, platelet concentrate,
and/or fresh frozen plasma (Compliant to AO 2015-0045)

2.2.2. NVBSP prescribed Blood Request Form for Adult and Pediatrics (Hospital-based only) for appropriate
indication for transfusion as stated in the Philippine Clinical Practice Guidelines for the Rational Use
of Blood and Blood Products and Strategies for Implementation
2.2.3. BSN meeting attendance
2.24. Compatibility testing/ Cross-matching Form

2.2.5. Commitment to support advocacy, voluntary blood donor recruitment and blood donation activities.

Assessment:

[|Recommended for issuance of Certificate of Inclusion.

[Not recommended for issuance of Certificate of Inclusion

Reasons:

Recommending Lead Blood Service Facility

Lead Blood Service Facility Supervisor Lead Blood Service Facility Head

Received Date: Time:

by:
Name Signature
of
ANNEX E
Checklist on Renewal of Application of Certificate of Inclusion

Name of the BSF:

Level of Facility (for hospital-based BSF):

for
Current BSF Category:

Check (/) if complied according to BSF

Requirements Category
BS BCU HBB BC/HBB+
1. Letter of Intent addressed to the CHD Director, Attention: the RBPC

and
2. Recent DOH-License To Operate

BC.
3. Certificate of Inclusion issued for the current year

4. Memorandum of Agreement with Lead BSF* OR

Memorandum of Agreement with Dialysis Clinic **

4.1. The Memorandum of Agreement shall be region specific. However, the MOA shall have the
following provisions that the satellite BSF shall comply. *

Blood
4.1.1.Commitment
B8Cy
to provide resources for Voluntary Blood Donation Activities for
HBR

Service
Manual
4.1.1.1. Total number of manpower involved in BSF based on category

a. List of dedicated personnel with designation

b.Job description with signed conforme

c. Copy of Contract of Service or appointment paper

4.1.1.2. Vehicle Availability

a. OR/CR of vehicle
4.1.1.3. Allotted budget for blood donation activities

a. Attach an operational plan or work and financial plan

4.1.1.4. List of appropriate equipment based on the

Facilit Standards
4.1.2. Enforce BSN commitment to synchronized collection and distribution;

4.1.2.1. Catchment Arca

a. List of Partners with MOA within the zonal BSN

4.1.2.2. Frequency of Mobile Blood Donation

a. Calendar of scheduled MBDs

4.1.2.3. Process flow from organizing blood donation, collection to distribution

4.1.2.4. Direct Distribution of Blood/Blood products

a. List of Blood Service Facilities within the zonal BSN

4.1.2.5. Network Meeting Attendance

4.1.3.4 functional and active HBTC is a prerequisite for the issuance of the COIL HBTC
minutes of the meeting with pictures (hospital-based only)

4.1.4.Patient billing statement reflecting fees for whole blood, packed red
blood cells, platelet
concentrate, and/or fresh frozen plasma (Compliant to AO 2015-0045)

4.1.5. Weekly Blood Inventory Management Report

4.1.6.Use of the NVBSP prescribed Bload Request Form for Adult and Pediatrics
(Hospital-based only) for appropriate indication for transfusion as stated in the
Philippine Clinical Practice Guidelines for the Rational Use of Blood and Blood
for Impl
"
Prodi
ies

St
 ANNEX E
Checklist on Renewal of Application of Certificate of Inclusion
4.2. Memorandum of Agreement (MOA) with Dialysis Clinic (free-standing or hospital-based
dialysis center not owned by the hospital) as end user**

4.2. L Patient billing statement reflecting fees for whole blood, packed red blood cells, platelet
concentrate, and/or fresh frozen plasma (Compliant to AO 2015-0045)

4.2.2.NVBSP prescribed Blood Request Form for Adult and Pediatrics (Hospital-based only) for
appropriate indication for transfusion as stated in the Philippine Clinical Practice
Guidelines for the Rational Use of Blood and Blood Products and Strategies for
Implementation

4.2.3.BSN meeting attendance

4.2.4.Compatibilitv testing/ Cross-matching Form

4.2.5.Commitment 10 support advocacy. voluntary blood donor recruitment and blood donation
activities.

5. Certificate or Proof of Subscription to the NBBNetS of NVBSP

6. Annual BSI Report (previous year)

7. Quarterly BM Report (Consolidated report from previous year and 1-2 quarter of the current year)

8. Certificate of Participation in EQAS in RITM TTI-NRL***

8. ***Prior to participating in NEQAS, RITM TTI-NRL shall require the following:

8.1. Certificate of HIV proficiency of the blood bank staff issued by RITM TTI-NRL
8.2. Update file on referred tested-reactive blood units for confirmation at RITM TTI NRL

NOTE:

For 8SBCU, both BS and BCU columns con be used to chock their tequiroments whichever is spplicable to the requirement stated.
Hosgilad Blood Bank with Additional Functions (HBB+) — ceflined as a hospital-based Hood service lacililies thal are Levels 2 and 3 Private and Government Hospitals thal may
continue blood collection from volunteer load dondrs; blood testing using the NVBSP recommended melhodokires and componant processing based an AO 2008-0006-4 and AC
201240012
ANNEX E
Checklist on Renewal of Application of Certificate of Inclusion

Assessment:
[JrRecommended for issuance of Certificate of Inclusion.

[Not recommended for issuance of Certificate of Inclusion

Reasons:

Recommending Lead Blood Service Facility

Lead Blood Service Facility Supervisor Lead Blood Service Facility Head

Received Date: Time:

by:
Name Signature
of
ANNEX F. Sample Recommendation Letter

Date:

JUAN DELA CRUZ, MD, MPH, CESO IV

Director IV
Metro Manila Center for Health Development
Welfareville Compound, Mandaluyong City

Attention: MS. JUANITA DELA CRUZ

Regional Blood Program Coordinator

the
Dear Director Dela Cruz:

Greetings!

Blood
Bank)
e.g.
(Bleed
In compliance with DOH NVBSP Department Memorandum No. 2016-0448 for the issuance
of a Certificate of Inclusion of Blood Service Facilities (BSFs), the (Name of Blood Service

Address
Facility) located has complied all

Category
at with
Service Facility)
(Complete

the requirements, enclosed herewith.

The (Name of the Lead Blood Service Facility) hereby recommends issuance of a
Certificate of Inclusion as for the
Service

Hospital

above mentioned BSF with the validity period from (January 1, 2021 to December 31,
2021).

Thank you.

Very truly yours,

DR. JJ DL. ZY, FPSP

Head
XYZ Blood Center

TE
 ANNEX G. Sample Template of COI

CONE NGXONGXONEX(NXNX
XX

oN)
Republic of the Philippines
X Department of Health
aN CALABARZON Center for Health Development
X
ONG
Certificate of Inclusion in the
X
(ONG
Regional Blood Services Network,
“¢

This certificate is issued to

G
Name of Blood Service Facility
¢
Address

{ Blood Service Facility Category

( Lead Blood Service Fadility

An active member ofthe National Voluntary Blood Services Program, Regional Blood Services Network,
pursuant to RA 7718, otheswise known as the National Blood Services Act of 1994, and its

/
Implementing Rules and Regulations, A.0.n0.95 s. 2005.

Issued this _____ day

of January yyyy,
Validity period is from day of January, yyyy to day of December, yyyy.

‘ NOT VALID WITHOUT DRY SEAL

JUAN DELA CRUZ, MD, MPHM, CESO
Director IV
CALABARZON Center for Health Development
III