Blood Transfusion Report

This must be submitted with every FFL-initiated transfusion prior to departing the receiving facility.

To the blood bank receiving this form:

These are uncrossmatched units given in the field for a life-threatening emergency. Please perform a post-transfusion crossmatch to evaluate for a potential transfusion reaction.
Flight Number: *
Base: *

Base: FFL1 Palestine FFL2 Mount Pleasant FFL3 Longview FFL4 Wills Point
Receiving hospital: *

Receiving hospital: CMFH TYLER Baylor Dallas Children's Dallas Medical City Plano Parkland UT Tyler Other
Who did you leave the empty bag (or segments) with? *

Please include full name and license/discipline.
If you don't have backup units at the base to restock, please text/call Bryan or Eric to see if you should pick up new units at FFL3 or FFL4 on your way back to base. *

If you don't have backup units at the base to restock, please text/call Bryan or Eric to see if you should pick up new units at FFL3 or FFL4 on your way back to base. Okay, will do Can't, due to duty time, Wx, etc. No need - we have backup units at the base to restock with
Please attach a picture of the 24B.02 BLOOD TRANSFUSION FORM here: *

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Blood Transfusion Report

Blood Transfusion Report

To the blood bank receiving this form: