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)

Pre Camp Motivational Session Conducted (required)

IEC Materials Provided by Blood Centre (required)

Donor Pin/Badge Provided (required)

Donor Certificated Provided (required)

Haemoglobin Check Done in Camp (required)

Oxygen Cylinder Present at Camp Site (required)

Emergency Medicines Present at Camp Site (required)

Blood Oscillating Machine Blood Mixer Available (required)

Weight Machine in Good Working condition (required)

Refrigerated Boxes with Dry Ice to Carry Blood Bags (required)

Cots in Good Condition used as donor couch (required)

Clean Bed Sheets (required)

Technician Working with Gloves in hand (required)

Electronic Data Entry done at Camp Site (required)

Individual Counselling Done (required)

Post Donation Care Explained (required)

All Field in Screening Form Duly Filled Up (required)

Post Donation Follow Up Done (required)

Donation Area (required)

Screening Area (required)

Haemoglobin Test Done Through (required)

Weight of Donors Properly Measured by (required)

Temperature of Blood Donors Properly Measured by (required)

Temperature of Blood Donors Measured by which type of Instrument (required)

Pulse and Blood Pressure Measured by (required)

Pulse Rate Measured by which instrument (required)

Complete Health Checkup including Cardiovascular System and Chest done (required)

The name and License Number of the Blood Centre were printed and Stamped on the screening Card (required)

Name and Regn. No. of the Medical Officer Printed and Stamped on the Screening Card (required)

Site of phlebotomy cleaned property with fresh cotton ball and isopropyl alcohol / disposable alcohol swab (required)

Blood Sample Taken in 2 Sample tubes of Red Cap and Lavender Cap (required)

Site of Phlebotomy Sealed Property After Donation (required)

Needles Destroyed by (required)

All disposable items were carried by the team (required)

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)

Behaviour of Staff (required)

Donors Properly Attended (required)

Donors Complications Take Care Off (required)

Deffered Donors Properly Counselled (required)

Details of Donor Complication if any

Star Rating for the Camp (required)

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)

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