OFFICE OF THE SECRETARY

PUNJAB BLOOD TRANSFUSION AUTHORITY

Inside Mental Hospital, Jail Road, Lahore Government of the Punjab
Health Department
No._______________/PBTA, DATED._________________2018.

Blood Bank Data Collection Form

Date: Data for (Month/Months/Year)------------

Name of Blood Bank/Institution:

Address:

Name of Incharge:

Telephone No: Fax No:

Mobile No: E-mail:

Structure

Your organization is a Hospital Blood Bank Thalassaemia Centre Blood Bank

Standalone Blood Bank

Blood Centre

Public sector Private/NGO sector

STAFFING

No of Staff: BTOs Technologists Technicians Assistants

Nurses Support Staff

Others:

Biological waste is disposed by?

Incininerator present: Yes No If Yes; In-house Outsourcerd

Inciniration performed; Daily Weekly Other

Documentation Yes No

What is the number of donors deferred? Main Cause of Deferral -----------------------

Number of rooms in the blood bank

No. of total Blood Donations collected?

No of units/donors screened

Voluntary non-remunerated donors Family/replacement donors

 OFFICE OF THE SECRETARY
PUNJAB BLOOD TRANSFUSION AUTHORITY
Inside Mental Hospital, Jail Road, Lahore Government of the Punjab
Health Department
No._______________/PBTA, DATED._________________2018.

How the blood was collected? Mobile camp collection

Blood Bank collection

No. of male blood donors No. of female blood donors

SCREENING

Is the screening for the following performed? Data for (Month/Months/Year)---------------------------------------

No. of tests No. of Methodology

Parameter Yes No
performed Positive Tests
Technique Manufacturer
HBV

HCV

HIV

Syphilis

Malaria

Equipment Status (Basic Equipment)

Sr. Name of Equipment Number Working/out of order

No
1. Blood storage Cabinet
2. Lab Centrifuge
3. Tube Stripper
4. Tube Sealer
5. Weighing Scale
6 Equipment for HB Estimation
7 Safety equipment and Supplies
8 Blood storage Cabinet
9 Plasma freezer (FFP)
10 TTI Screening Equipment
11 Water Bath
12 Refrigerated Centrifuge
13 Plasma Extractor
14 Others
 OFFICE OF THE SECRETARY
PUNJAB BLOOD TRANSFUSION AUTHORITY
Inside Mental Hospital, Jail Road, Lahore Government of the Punjab
Health Department
No._______________/PBTA, DATED._________________2018.

Is the whole blood processed for component preparation? Yes No

What is the number of blood separated into components?

Which components were prepared (give number prepared )?

Red Cell Concentrate Fresh Frozen Plasma Cryoprecipitate

Platelet Concentrates Single Donor Platelet Apheresis

Is there a hospital transfusion committee? Yes No

If Yes, When it was established?

Is Blood Transfusion Information Management System (BTIS software) is available? Yes No

Number of Blood transfusion committee meetings and date of last meeting______________________________

__________________________________________________________________________________________

Signature with Date

Designation