BLOOD CAMP FEEDBACK FORM Name of Blood Camp Motivating Organisation (required) Name of the Organisation organising Blood Camp (required) Name of Blood Camp Organiser (required) Address (required) Email ID (required) Phone Number (required) Camp Code (required) Name of Blood Centre (required) Date of Camp Booking (required) Date of Camp (required) Time of Arrival of Mobile Blood Collection Team (required) End time of Camp (required) Donation Check list & Report Pre Camp Visit from Blood Centre (required) YesNo Pre Camp Motivational Session Conducted (required) YesNo IEC Materials Provided by Blood Centre (required) YesNo Donor Pin/Badge Provided (required) YesNo Donor Certificated Provided (required) YesNo Haemoglobin Check Done in Camp (required) YesNo Oxygen Cylinder Present at Camp Site (required) YesNo Emergency Medicines Present at Camp Site (required) YesNo Blood Oscillating Machine Blood Mixer Available (required) YesNo Weight Machine in Good Working condition (required) YesNo Refrigerated Boxes with Dry Ice to Carry Blood Bags (required) YesNo Cots in Good Condition used as donor couch (required) YesNo Clean Bed Sheets (required) YesNo Technician Working with Gloves in hand (required) YesNo Electronic Data Entry done at Camp Site (required) YesNo Individual Counselling Done (required) YesNo Post Donation Care Explained (required) YesNo All Field in Screening Form Duly Filled Up (required) YesNo Post Donation Follow Up Done (required) YesNo Donation Area (required) Ac roomVentilated non ac roomMobile blood collection vanTemporary structureOpen air Screening Area (required) CoveredOpen Haemoglobin Test Done Through (required) CuSO4HEAMOQUENOT DONE Weight of Donors Properly Measured by (required) MBBS DoctorInternTechnicianNurse/PhlebotomistVolunteerNot Done Temperature of Blood Donors Properly Measured by (required) MBBS DoctorInternTechnicianNurse/PhlebotomistVolunteerNot Done Temperature of Blood Donors Measured by which type of Instrument (required) DigitalAnalogNot Done Pulse and Blood Pressure Measured by (required) MBBS DoctorInternTechnicianNurse/PhlebotomistVolunteerNot Done Pulse Rate Measured by which instrument (required) Dial TypeDigitalNot Done Complete Health Checkup including Cardiovascular System and Chest done (required) YesNo The name and License Number of the Blood Centre were printed and Stamped on the screening Card (required) YesNo Name and Registration Number of the Medical Officer Printed and Stamped on the Screening Card (required) YesNo Site of phlebotomy cleaned property with fresh cotton ball and isopropyl alcohol / disposable alcohol swab (required) YesNo Blood Sample Taken in 2 Sample tubes of Red Cap and Lavender Cap (required) YesNo Site of Phlebotomy Sealed Property After Donation (required) Sticking plasterCollodion in cotton ballOnly cotton ballNot sealed Needles Destroyed by (required) Needle crusherCut off by scissors from blood bagKept intact with blood bag All disposable items were carried by the team (required) YesNo Number of Enrolled interested blood donors (required) Number of Donation (required) Number of Blood Donors (Male) Number of Blood Donors (Female) Number of First Time Blood Donors (Male) Number of First Time Blood Donors (Female) Number of Blood Donors Deferred (Male) Number of Blood Donors Deferred (Female) Number of Donor Reactions (Male) Number of Donor Reactions (Female) Refreshment Provided to Donor (required) Details of Any valuables Provided to Donors (required) Upload Picture of Valuable Gifts to Donors (if any) Grading of the Camp by the Organisers Medical Screening (required) PoorNot SatisfiedAverageSatisfiedVery Satisfied Behaviour of Staff (required) PoorNot SatisfiedAverageSatisfiedVery Satisfied Donors Properly Attended (required) PoorNot SatisfiedAverageSatisfiedVery Satisfied Donors Complications Take Care Off (required) PoorNot SatisfiedAverageSatisfiedVery Satisfied Deffered Donors Properly Counselled (required) PoorNot SatisfiedAverageSatisfiedVery Satisfied Details of Donor Complication if any Star Rating for the Camp (required) 12345 Name of Medical Officer (required) Registration Number of Medical Officer (required) Phone Number of Medical Officer Email ID of Medical Officer Name and Designation of all Members of the Medical Team Upload Photographs of Camps (if any)