Monthly

Unique ID no of blood Bank

Section A : Monthly input Formats for Blood Banks

Name of the Blood Bank

Address of Blood Bank

Taluk

District

Pincode

Name of Blood Bank Nature

Blood Component Seperation Facility Available?

Status of license : valid upto(dd/mm/yyyy) Applied for Renewal

License Number -

Period

Month

Year

Blood Bank Supported by

Name of officer in-charge

Section B : Blood units collected during the Month

Blood Donation at blood bank

Blood donation at Voluntary
Blood Donation Camps

Total

Type of Blood Donors

Male Donors

Female Donors

Male Donors

Female Donors

Male

Female

Total

Voluntary Blood Donors

[V_MaleDonorsViaBB]

[V_FemaleDonorsViaBB]

[V_MaleDonorsViaCAMP]

[V_FemaleDonorsViaCAMP]

[V_TotalMaleDonors]

[V_TotalMaleDonorPer]

[V_TotalFemaleDonors]

[V_TotalFemaleDonorPer]

[V_TotalDonors]

Replacement Blood Donors

[R_MaleDonorsViaBB]

[R_FemaleDonorsViaBB]

[R_MaleDonorsViaCAMP]

[R_FemaleDonorsViaCAMP]

[R_TotalMaleDonors]

[R_TotalMaleDonorPer]

[R_TotalFemaleDonors]

[R_TotalFemaleDonorPer]

[R_TotalDonors]

Total

[VR_MaleDonorsViaBB]

[VR_FemaleDonorsViaBB]

[VR_MaleDonorsViaCAMP]

[VR_FemaleDonorsViaCAMP]

[VR_TotalMaleDonors]

[VR_TotalMaleDonorPer]

[VR_TotalFemaleDonors]

[VR_TotalFemaleDonorPer]

[VR_TotalDonors]

No. of Donors coming for repeat donation

No. of Voluntary Blood Donation Camps organized

No. of Blood Donors Counseled

No. of Blood Donors referred to ICTC

II. Status of Testing : Transfusion Transmitted infections of blood units

Test Conducted	Voluntary Collection Units				Replacement Collection Units				Total Collection
	Tested		Positive		Tested		Positive		Voluntary		Replacement
	M	F	M	F	M	F	M	F	Tested	Positive	Tested	Positive
HIV	[HIV_V_MaleDonors]	[HIV_V_FemaleDonors]	[HIV_V_MaleInfected]	[HIV_V_FemaleInfected]	[HIV_R_MaleDonors]	[HIV_R_FemaleDonors]	[HIV_R_MaleInfected]	[HIV_R_FemaleInfected]	[HIV_V_Donors]	[HIV_V_Infected]	[HIV_R_Donors]	[HIV_R_Infected]
Hepatitis - B	[HEPATITIS-B_V_MaleDonors]	[HEPATITIS-B_V_FemaleDonors]	[HEPATITIS-B_V_MaleInfected]	[HEPATITIS-B_V_FemaleInfected]	[HEPATITIS-B_R_MaleDonors]	[HEPATITIS-B_R_FemaleDonors]	[HEPATITIS-B_R_MaleInfected]	[HEPATITIS-B_R_FemaleInfected]	[HEPATITIS-B_V_Donors]	[HEPATITIS-B_V_Infected]	[HIV_R_Donors]	[HIV_R_Infected]
Hepatitis - C	[HEPATITIS-C_V_MaleDonors]	[HEPATITIS-C_V_FemaleDonors]	[HEPATITIS-C_V_MaleInfected]	[HEPATITIS-C_V_FemaleInfected]	[HEPATITIS-C_R_MaleDonors]	[HEPATITIS-C_R_FemaleDonors]	[HEPATITIS-C_R_MaleInfected]	[HEPATITIS-C_R_FemaleInfected]	[HEPATITIS-C_V_Donors]	[HEPATITIS-C_V_Infected]	[HEPATITIS-C_R_Donors]	[HEPATITIS-C_R_Infected]
VDRL	[VDRL_V_MaleDonors]	[VDRL_V_FemaleDonors]	[VDRL_V_MaleInfected]	[VDRL_V_FemaleInfected]	[VDRL_R_MaleDonors]	[VDRL_R_FemaleDonors]	[VDRL_R_MaleInfected]	[VDRL_R_FemaleInfected]	[VDRL_V_Donors]	[VDRL_V_Infected]	[VDRL_R_Donors]	[VDRL_R_Infected]
Malaria	[MALARIA_V_MaleDonors]	[MALARIA_V_FemaleDonors]	[MALARIA_V_MaleInfected]	[MALARIA_V_FemaleInfected]	[MALARIA_R_MaleDonors]	[MALARIA_R_FemaleDonors]	[MALARIA_R_MaleInfected]	[MALARIA_R_FemaleInfected]	[MALARIA_V_Donors]	[MALARIA_V_Infected]	[MALARIA_R_Donors]	[MALARIA_R_Infected]

III. Details of Blood and Blood Components

[StockTable]

Staff		No. of Sanctioned	No in place	Trained? 1+yes 2=No	Type of training Recd(*)
1	Medical Officer
2	Blood Bank Technician
3	Nurse
4	Laboratory Assistant
5	Lab Attendant
6	Counsellor
7	Social Worker
8	Data Entry Operator

*) (1) Introduction (2) Orientation (3) Others

IV. Status of Equipments

Sl No	Name of Equipment	Number	Make/Brand	Functional Status 1=yes, 2=No	AMC Status 1=Yes, 2=No
	Blood Bank Refrigerator
	Donor Couches
	Biomixer
	Tube Sealer
	Di-electric Sealer
	Domestic Refrigerator
	Bench Top Centrifuge
	Dry Incubator
	Serological Water Bath
	Autoclave
	Binocular Microscope
	Micro Pipettes(2ul-2000ul)
	Multi Channel Pipette
	Distilled Water Still

V. Number of Blood Units Discarded & Reason

[DiscardedStock]