Form: CA_Blood_Bank_Order_Form_Initial.html,CA_Blood_Bank_Order_Form_Viewer.html

To: 
Subject: CA Blood Bank Order/Inventory-<var Req_Hosp>
SeqInc:
Msg:

REQUESTING HOSPITAL: <var Req_Hosp>

Hospital Tech Name: <var Tech_Name>
Date/Time: <var Time1>

    Leuko-Reduced Red Blood Cells (RBCL)

O Positive>  SL: <var Stock_1>  ACTUAL: <var Act1>  ORDER: <var Ord1>  

O Negative>  SL: <var Stock_2>  ACTUAL: <var Act2>  ORDER: <var Ord2> 
 
A Positive>  SL: <var Stock_3>  ACTUAL: <var Act3>  ORDER: <var Ord3> 

A Negative>  SL: <var Stock_4>  ACTUAL: <var Act4>  ORDER: <var Ord4> 

B Positive>  SL: <var Stock_5>  ACTUAL: <var Act5>  ORDER: <var Ord5> 

B Negative>  SL: <var Stock_6>  ACTUAL: <var Act6>  ORDER: <var Ord6> 

AB Positive> SL: <var Stock_7>  ACTUAL: <var Act7>  ORDER: <var Ord7> 

AB Negative> SL: <var Stock_8>  ACTUAL: <var Act8>  ORDER: <var Ord8>
 
TOTALS> SL: <var Total1>  Actual: <var Total2>  Order: <var Total3> 
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    Leuko-Reduced Irradiated Red Blood Cells (RBCLI)

O+, cmv->  SL: <var Stock_9>  ACTUAL: <var Act9>  ORDER: <var Ord9>  

O-, cmv->  SL: <var Stock_10>  ACTUAL: <var Act10>  ORDER: <var Ord10> 
 
A+, cmv->  SL: <var Stock_11>  ACTUAL: <var Act11>  ORDER: <var Ord11> 

A-, cmv->  SL: <var Stock_12>  ACTUAL: <var Act12>  ORDER: <var Ord12> 

TOTALS> SL: <var Total4>  Actual: <var Total5>  Order: <var Total6> 
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    Leuko-Reduced Platelets (APLT)

PLATELETS A/T>  SL: <var Stock_13>  ACTUAL: <var Act13>  ORDER: <var Ord13>  

PLATELETS Irr>  SL: <var Stock_14>  ACTUAL: <var Act14>  ORDER: <var Ord14> 
 
TOTALS> SL: <var Total7>  Actual: <var Total8>  Order: <var Total9>

Special Instructions:

 <var SpecInst>
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    Frozen Plasma (200-399ml) 

O>  SL: <var Stock_15>  ACTUAL: <var Act15>  ORDER: <var Ord15>  

A>  SL: <var Stock_16>  ACTUAL: <var Act16>  ORDER: <var Ord16> 
 
B>  SL: <var Stock_17>  ACTUAL: <var Act17>  ORDER: <var Ord17> 

AB> SL: <var Stock_18>  ACTUAL: <var Act18>  ORDER: <var Ord18> 

TOTALS> SL: <var Total10>  Actual: <var Total11>  Order: <var Total12>
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    Single Cryo (CAF) Pooled Cryo (CAF PL) 

CAF A>   SL: <var Stock_19>  ACTUAL: <var Act19>  ORDER: <var Ord19>  

CAF AB>  SL: <var Stock_20>  ACTUAL: <var Act20>  ORDER: <var Ord20> 
 
CAF PLA> SL: <var Stock_21>  ACTUAL: <var Act21>  ORDER: <var Ord21> 

TOTALS> SL: <var Total13>  Actual: <var Total14>  Order: <var Total15>
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Additional Comments from Requesting Hospital:

 <var Comments>
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                    Below This Line for SDBB Staff Use 
                                  NOTEPAD AREA:

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SDBB HSR Filling Order:                 
Date:
Time: