ISBT RARE DONOR WORKING PARTY INTERNATIONAL SHIPMENT OF

isbt rare donor working party - international shipment of rare blood response form receiving/requesting centre remarks institution info

ISBT RARE DONOR WORKING PARTY - INTERNATIONAL SHIPMENT OF RARE BLOOD
RESPONSE FORM
RECEIVING/REQUESTING CENTRE REMARKS
Institution Information:
Receiving Institution:
Sending Institution:
Facility Name: __________________________
City: __________________________
Country: __________________________
Date Received: __________________________
Facility Name: ____________________________
City: ____________________________
Country: ____________________________
Please provide answers to the following:
1. Number of RBC units received: _____
Were the units received in acceptable condition?
If no, what was the problem?
Broken: _____ # ______
Thawed:_____ # ______
Other: ______________________________________
Yes
No
2. Were the units received at the expected time?
If no, what was the problem?
___________________________________________________
___________________________________________________
Yes
No
3a. Were the infectious disease tests performed and documented?
3b. Were they sufficient to allow transfusion?
Yes
Yes
No
No
4. Were the billing documents in order?
If no, what was the problem?
___________________________________________________
___________________________________________________
Yes
No
5. What was the transfusion outcome?
a. Patient received units?
If no, please give reason: _________________________
_____________________________________________
b.
Please describe outcome of patient.
______________________________________________
______________________________________________
______________________________________________
Yes
No
6. Phenotype of Units: _______________________________________
# received: _________
Name of individual completing form
___________________________Date:____/_____/_____
(day/month/year)
Fax: Email:
IBGRL FAX: 44 117 921 7329 IBGRL email: [email protected]
Shipping Center FAX: _____________ Shipping Center
email:____________________
Country of Receipt _____________ Country of Receipt:
____________________
Instructions for Review and Use of Receiving/Requesting Centre Remarks
Form
(for Internationally Shipped Rare Blood Units)
1.
Review template for ISBT Rare Donor Working Party - International
Shipment of Rare Blood Response Form Receiving/Requesting Centre
Remarks
a.
Translate into host country’s language, if desired.
b.
Add appropriate host country’s FAX number, if desired.
c.
Approve through appropriate local channels/change control system
d.
Notify shipping/receiving facilities of new monitoring process
e.
Distribute forms according to local process
2.
Instructions for using the ISBT Rare Donor Working Party -
International Shipment of Rare Blood Response Form
Receiving/Requesting Centre Remarks
a.
Shipping facility includes form with units to be shipped
b.
Receiving facility completes form answering all questions and
blanks
c.
Receiving facility faxes or emails completed form to:
i.
IBGRL
ii.
National Organization of Country (if applicable)
iii.
Shipping facility
d.
File form with shipment paperwork, as desired.