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PRINTABLE FORMS

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Transfer Document (BS 5150) – If our customer portal is not available in your area or if the portal is temporarily not available, use this document to return components to Vitalant OR to ship components hospital-to-hospital outside of your hospital network OR to ship components hospital-to-hospital within your hospital network when the receiving hospital is not on the computer system your hospital uses. Multiple copies may be photocopied or printed from the website if additional copies of the completed form are required.

To transfer components between hospitals using the BS 5150, the sending facility must inspect each blood component, sign the blood storage and handling statement, document the date and time of component inspection/packing and identify, on the BS 5150, the person performing the inspection and packing. Place the original BS 5150 in the shipper and retain a copy at the hospital.

The receiving hospital must inspect the packing configuration and document acceptability, measure and record the receipt temperature of the shipment, verify shipper contents and sign the “Received By” section of the BS 5150, recording the date and time of receipt. Send a completed copy of the form to the local Vitalant center and retain a copy at the hospital.

Emergency Release Document (BS 5341) – A physician, hospital or other medical facility uses the BS 5341, Emergency Release Document, to ask Vitalant to issue whole blood and blood components before all the required laboratory testing has been completed. Such emergency releases require the approval of a Vitalant physician before the blood can be shipped or delivered. The requesting facility should complete the Patient Information and then fax or scan the BS 5341 to Vitalant for sign off.

Special Order Form (BS 129S) – If our customer portal is not available in your area or if the portal is temporarily not available, use this document to communicate special orders to the blood center (e.g., antigen-negative RBCs, irradiated components, etc.). Hospitals fill out the large box above the heavy horizontal line as completely as possible. The form may be completed online; then, it must be printed and faxed to the blood center.  (View a directory of centers and fax numbers here.)

Customer Product Credit Request (BS 340) – If our customer portal is not available in your area or if the portal is temporarily not available, use this form to document a request for credit for non-usable or damaged blood components. The form may be completed electronically; then, it must be printed and faxed to the blood center or prepared for pick-up by a blood center courier. (View a directory of centers and fax numbers here.)

Reference Laboratory Request Form (BS 313) – This form is used to request testing through the immunohematology reference laboratory. View the BS 313 Submission Tips.

Report of Transfusion Associated Infection form (BS 314) – This form is used to report all clinically significant (non-bacterial) infections or infectious diseases in recipients of blood products that could have resulted from transfusion and for which another, more likely cause is not apparent.

Special Collections Form (BS 365) –This form is used to document a physician’s request for an autologous or directed donation.

Therapeutic Phlebotomy Form (BS 365T) –This form is used to document a physician’s request for a therapeutic collection.

Attending Physician’s Request for Therapeutic Apheresis (BS 702)– This form is used to document a physician’s request for a Therapeutic Apheresis procedure.

Therapeutic Apheresis Informed Consent (BS 707A) – Physician uses this form to describe therapeutic apheresis procedures to the patient or legal guardian prior to the procedure being performed.

Report of Transfusion Adverse Reaction form (AABB)–This form is used to report all transfusion adverse reactions which occurred in blood or blood component recipients such as suspected TRALI, suspected bacterial contamination and other types of reactions believed to be due to an attribute specific to the donor or the processing of the blood products.

Vitalant, one of the nation’s oldest and largest nonprofit community blood service providers, supplies comprehensive transfusion medicine services to nearly 1,000 hospitals and health care partners for patients in need across 40 states.