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NBBNETS Registration Form v2

The document is a registration form for blood service facilities to join the National Blood Bank Network System (NBBNetS) in the Philippines. It collects information such as the facility name, address, license details, ownership, processes performed, and whether an information system or donation ID stickers are used. The form is signed by both the facility head and a section head to confirm the provided information before the National Voluntary Blood Service Program reviews and processes the registration.

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sanleonardohospitallaboratory
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3K views1 page

NBBNETS Registration Form v2

The document is a registration form for blood service facilities to join the National Blood Bank Network System (NBBNetS) in the Philippines. It collects information such as the facility name, address, license details, ownership, processes performed, and whether an information system or donation ID stickers are used. The form is signed by both the facility head and a section head to confirm the provided information before the National Voluntary Blood Service Program reviews and processes the registration.

Uploaded by

sanleonardohospitallaboratory
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Republic of the Philippines

Department of Health
NATIONAL VOLUNTARY BLOOD SERVICE PROGRAM
5th Flr., Philippine Blood Center, Lung Center Compound, Quezon Avenue, Quezon City
Telephone No: (02) 995-3846 local 249/213/214

National Blood Bank Network System (NBBNetS)


Registration Form

Blood Service Facility Information


Region: Date of Registration:

Province: City / Municipality:

Name of Blood
Service Facility:

Complete Address:

Landline Number: Fax Number:

Mobile Number: E-mail Address:

License Number: Date Issued: Date of Expiry:

Facility Type: Free-standing Hospital-based


Blood Center Blood Bank Blood Bank with provision
Facility Category:
Blood Station Blood Collecting Unit Others:
GOV-DOH GOV-LGU Private
Facility Ownership:
PRC Others :
Head of BSF
(Pathologist) :

Complete Name of
Contact Person:
Mobile Number: E-mail Address:

Blood Service Facility Processes


YES NO
1. Blood Collection
2. Blood Component Processing
3. TTI Testing
4. Blood Dispensing
5. Compatibility Testing
Others :

Does your facility implement an information system? (LIS, BBIS, HIS)


Do you use the NVBSP Donation ID stickers?

Checked By : Noted By:

Section Head Head of Facility


(Signature over printed name) (Signature over printed name)

Received by : (for NVBSP use only)

NVBSP-IMU Staff
(Signature over printed name, date)

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