Page 5 - Demo

4%u201d x 5%u201d Clear Film Dressing16.5%u201d MarkedBeaded Cord1NAR AlcoholPrep Pads2Blood BagSingle, 450 ml1NitrileGloves, Lg1NitrileGloves, Lg1DonorPlacard1QTY550 Cord10 in.1QTY4%u201d x 4%u201dGauze Pad (2pk)2QTY5.5%u201d Kelly Hemostat (Disposable)1QTYConstrictingIV Band1QTY PermanentMarker, Large1QTYBLOOD BAG LABELBRN: Blood Type: Low Titer: YES NOCollection Time: Administration Time: Collected By: Administered By: REV121616 %u2022 ZZ-0836Blood BagSticker1QTYChloraprepSwabsticks,3pk2QTYSurgicalTape, 1 in.QTY15mL Purple Top Vacutainer4QTY5mL Red Top Vacutainer2QTY21G EclipseVacutainer Holder1QTY%u2022 Comprehensive kit designed for use with the Quantum%u2122 Blood & Fluid Warming System allowing rapid, consistent normothermic field blood transfusion in far forward and near point of injury (POI) prehospital casualty management. %u2022Includes the Quantum%u2122 Thermal Transfusion Set - (Blood) that incorporates an integrated heating system that does not disrupt the fluid path%u2022 Equipped with Donor/Recipient Modules to verify blood types of the donor and recipient%u2022 Also allows collecting of blood samples from the donor for additional surveillance testingSPECIFICATIONS L 10 in. x W 7 in. x D 2.5 in. Weight: 1.09 lbField Blood Transfusion Kit%u2122ITEM # NSN #83-0028 ---QUANTUMTM FIELD BLOOD TRANSFUSION KITQUANTUM%u2122 FIELD BLOOD TRANSFUSION KIT CONTENTS:All the needed supplies to allow the user to rapidly perform a field blood transfusion as outlined in theJoint Theater Trauma System Clinical Practice GuidelinesEach Donor Module Kit contains:Each Recipient Module Kit contains:EldonCard1QTYRECIPIENTZZ-0850 REV01062017RecipientCard1QTY QuantumTTS-B Set1QTY Single Blood Bag1QTY Permanent Marker, Large1QTY DonorModule Kit1QTY RecipientModule Kit1QTYSF-518Card1QTY SurgicalTape, 1 in.QTY14%u201d x 4%u201dGauze Pad (2pk)2QTYIV Catheter16G x 1.25%u201d1QTY550 Cord10 in.1QTYIV Catheter18G x 1.25%u201d1QTYConstrictingIV Band1QTYY-Type IVSet w/ Filter1QTY PermanentMarker, Large1QTYChloraprepSwabsticks, 3pk2QTYSurgicalTape, 1 in.QTY15.5%u201d Kelly Hemostat (Disposable)1QTYNitrileGloves, Lg24%u201d x 5%u201d Clear Film Dressing1NAR AlcoholPrep Pads26.5%u201d MarkedBeaded Cord1 PRE-SCREEN / EMERGENCYWHOLE BLOOD DONATION RECORD Form is only to be used for preInformation to be obtained and reviewed by HIPAA trained healthcare professionals only -screening or collecting donors in support of contingency / deployed operations.DONATION IDENTIFICATION NUMBER (DIN)(Use Donor SSN if ISBT # Not Available) TODAY%u2019S DATE NAME (Last, First, Middle Initial) RANK/RATE USA USAF USN USMC CIV SSN:DoD ID: UNIT UNIT LOCATION (Base and State) AOR BASE & TENT# (if deployed)DOB (DDMMMYYYY) SEX: M F ABO/Rh (Blood Type) CURRENT MAILING ADDRESS EMAIL ADDRESS BEST CONTACT PHONE NUMBERGroup A Questions (ALL DONORS Must Complete)1 Have you read and do you understand the educational materials provided to you?Y N 5 Have you ever received money, drugs, or other payment for sex? Y N2 Have you ever used needles to take drugs, steroids, or anythingnot prescribed by your doctor?Y N 6 Have you ever had cancer, heart problems, bleeding conditions, orlung disease?Y N3 Have you taken any of the medications listed on the back of this form within the timeframes shown? If Yes, write medications here: ________________________________________________Y N 7 Have you ever had hepatitis, or have you ever taken medication fortreatment or exposure to hepatitis?Y N4 Have you ever had a positive test for the HIV/AIDS virus? Y N 8 Have you ever had Malaria, Chagas or Babesiosis? Y N***Interviewer: Document review and eligibility below for walking blood bank (WBB) and/or low titer group O whole blood (LTOWB) donor program.*** DONORS: If you are being prescreened for a WBB or LTOWB program, STOP!! Answer no more questions and sign at the bottom. If you are here to donate a unit of blood, proceed to Group B Supplemental Questions and then sign at the bottom.Group A responses acceptable(all no except Q1)? Y N***Interviewer (initials):All disease tests negative?Y NEligible for WBB?Y NTiter Result (If group O):____________(accept if < 256)Eligible for LTOWB?Y NApproving Official Low Titer ID Issued?Y N NAComments:Group B Supplemental Questions (Complete if Donating a Unit of Blood Today)9 Are you feeling healthy and well today? Y N 18 In the past 12 months, have you lived with or had sex with a personwho has hepatitis?Y N10 Female donors: Have you ever been pregnant or are youpregnant now? Y N 19 In the past 12 months, have you had a transplant (such as organ,tissue, or bone marrow) or graft (such as bone or skin)?Y N11 Female donors: Have you had sexual contact with a male whohad sexual contact with another male in the past 12 months?Y N 20 In the past 12 months, have you had sexual contact with anyone whohas HIV/AIDS or has had a positive test for the HIV/AIDS virus?Y N12 Male donors: In the past 12 months, have you had sexualcontact with another male? Y N 21 In the past 12 months, have you come into contact with someoneelse%u2019s blood?Y N13 Are you currently taking malaria prophylaxis? Y N 22 In the past 12 months, have you had an accidental needle-stick? Y N14 Are you currently taking any medications for an infection? Y N 23 In the past 12 months, have you had a blood transfusion? Y N15 Have you had physical contact with someone who was vaccinated for smallpox in the past 8 weeks?Y N 24 In the past 12 months, have you had sexual contact with anyone whotakes money or drugs or other payment for sex?Y N16 In the past 48 hours, have you taken aspirin or anything that has aspirin in it?Y N 25 In the past 12 months, have you had or been treated for syphilis orgonorrhea?Y N17 In the past 8 weeks, have you donated blood, platelets, orplasma?Y N 26 In the past 12 months, have you had sexual contact with anyone whohas ever used needles to take drugs or steroids, or anything notprescribed by their doctor?Y NComments:Today%u2019s Date: Temperature:________%u00b0F/%u00b0C(%u2264 99.5%u00b0F/37.5%u00b0C)Blood Pressure:_______/_______Systolic: 90-180Diastolic: 50-100 Pulse:_____________(50-100 bpm) Hemoglobin:________________ Male: %u2265 13.0 g/dLFemale: %u226512.5 g/dL Weight:________________(%u2265 110 pounds/50kg) Vital Signs Tech:Does Donor Qualify? Y N***Reviewer (initials):Phlebotomist Start Time Stop Time(<15 mins) Bag Manufacturer Lot # Expiration Date: Segment #I verify that I have answered the questions honestly, I had an opportunity to ask questions, I consent to donating blood today, and I feel my blood is safe to be transfused. If Iam donating a unit of whole blood today, my blood will NOT be tested for viral diseases prior to transfusion due to the emergency situation. If for any reason I feel that myblood may not be safe, I will not donate today. ______________________________________________________________________________ Donor%u2019s Signature DateASBP 572-EWB (Emergency Whole Blood), 5 Apr 2018Check Deferral Status (initials):__________ Date: _____________ Entered into Blood Management System by (initials)__________ Date:_____________REV022324 ZZ-1623ASBP 572-EWB V291QTY PRE-SCREEN / EMERGENCYWHOLE BLOOD DONATION RECORD Form is only to be used for preInformation to be obtained and reviewed by HIPAA trained healthcare professionals only -screening or collecting donors in support of contingency / deployed operations.DONATION IDENTIFICATION NUMBER (DIN)(Use Donor SSN if ISBT # Not Available) TODAY%u2019S DATE NAME (Last, First, Middle Initial) RANK/RATE USA USAF USN USMC CIV SSN: DoD ID: UNIT UNIT LOCATION (Base and State) AOR BASE & TENT# (if deployed)DOB (DDMMMYYYY) SEX: M F ABO/Rh (Blood Type) CURRENT MAILING ADDRESS EMAIL ADDRESS BEST CONTACT PHONE NUMBERGroup A Questions (ALL DONORS Must Complete)1 Have you read and do you understand the educational materials provided to you?Y N 5 Have you ever received money, drugs, or other payment for sex? Y N2 Have you ever used needles to take drugs, steroids, or anythingnot prescribed by your doctor?Y N 6 Have you ever had cancer, heart problems, bleeding conditions, orlung disease?Y N3 Have you taken any of the medications listed on the back of this form within the timeframes shown? If Yes, write medications here: ________________________________________________Y N 7 Have you ever had hepatitis, or have you ever taken medication fortreatment or exposure to hepatitis?Y N4 Have you ever had a positive test for the HIV/AIDS virus? Y N 8 Have you ever had Malaria, Chagas or Babesiosis? Y N***Interviewer: Document review and eligibility below for walking blood bank (WBB) and/or low titer group O whole blood (LTOWB) donor program.*** DONORS: If you are being prescreened for a WBB or LTOWB program, STOP!! Answer no more questions and sign at the bottom. If you are here to donate a unit of blood, proceed to Group B Supplemental Questions and then sign at the bottom.Group A responses acceptable(all no except Q1)? Y N***Interviewer (initials):All disease tests negative?Y NEligible for WBB?Y NTiter Result (If group O):____________(accept if < 256)Eligible for LTOWB?Y NApproving Official Low Titer ID Issued?Y N NAComments:Group B Supplemental Questions (Complete if Donating a Unit of Blood Today)9 Are you feeling healthy and well today? Y N 18 In the past 12 months, have you lived with or had sex with a personwho has hepatitis?Y N10 Female donors: Have you ever been pregnant or are youpregnant now? Y N 19 In the past 12 months, have you had a transplant (such as organ,tissue, or bone marrow) or graft (such as bone or skin)?Y N11 Female donors: Have you had sexual contact with a male whohad sexual contact with another male in the past 12 months?Y N 20 In the past 12 months, have you had sexual contact with anyone whohas HIV/AIDS or has had a positive test for the HIV/AIDS virus?Y N12 Male donors: In the past 12 months, have you had sexualcontact with another male? Y N 21 In the past 12 months, have you come into contact with someoneelse%u2019s blood?Y N13 Are you currently taking malaria prophylaxis? Y N 22 In the past 12 months, have you had an accidental needle-stick? Y N14 Are you currently taking any medications for an infection? Y N 23 In the past 12 months, have you had a blood transfusion? Y N15 Have you had physical contact with someone who was vaccinated for smallpox in the past 8 weeks?Y N 24 In the past 12 months, have you had sexual contact with anyone whotakes money or drugs or other payment for sex?Y N16 In the past 48 hours, have you taken aspirin or anything that has aspirin in it?Y N 25 In the past 12 months, have you had or been treated for syphilis orgonorrhea?Y N17 In the past 8 weeks, have you donated blood, platelets, orplasma?Y N 26 In the past 12 months, have you had sexual contact with anyone whohas ever used needles to take drugs or steroids, or anything notprescribed by their doctor?Y NComments:Today%u2019s Date: Temperature:________%u00b0F/%u00b0C(%u2264 99.5%u00b0F/37.5%u00b0C) Blood Pressure:_______/_______Systolic: 90-180Diastolic: 50-100 Pulse:_____________(50-100 bpm) Hemoglobin:________________ Male: %u2265 13.0 g/dLFemale: %u226512.5 g/dL Weight:________________(%u2265 110 pounds/50kg) Vital Signs Tech:Does Donor Qualify? Y N***Reviewer (initials):Phlebotomist Start Time Stop Time(<15 mins) Bag Manufacturer Lot # Expiration Date: Segment #I verify that I have answered the questions honestly, I had an opportunity to ask questions, I consent to donating blood today, and I feel my blood is safe to be transfused. If Iam donating a unit of whole blood today, my blood will NOT be tested for viral diseases prior to transfusion due to the emergency situation. If for any reason I feel that myblood may not be safe, I will not donate today. ______________________________________________________________________________ Donor%u2019s Signature DateASBP 572-EWB (Emergency Whole Blood), 5 Apr 2018Check Deferral Status (initials):__________ Date: _____________ Entered into Blood Management System by (initials)__________ Date:_____________REV022324 ZZ-1623ASBP 572-EWB V291QTY