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
