Full Name of the applicant
Residential Address of the applicant
Technical Qualifications of the applicant
Name of the nursing home/hospital
Place where the nursing home is situated
Nursing Home Contact No:
Brief description of the construction size and equipments of the nursing home/hospital or any premises used in connection therewith
Whether the nursing home or any premises used in connection are used or are to be used for purposes otherthan that or carrying on a nursing home/hosp YesNo
Name age and qualification (s) of the medical practitioner (s) supervising the nursing home/hosp.
Name, age, qualification (s) of the visiting physicians and surgeons in the nursing home/hosp.
Total no. of beds
No. of beds for maternity patients
No. of beds for other patients: (specialty wise)
No. of free beds. (if applicable)
Distance of nursing home/hosp.From nearestblood bank
Mention monthly blood Unit’s utilisation.
Mention annually blood Unit’s utilisation.
Number of single unit transfusions in a year
Number of major surgeries done per year.
Number of minor surgeries done per year.
Whether operation theatre facility is available at your hospital. YesNo
Is your blood bank affiliated to any existing blood bank in the district YesNo
From which blood bank you are making blood available to the patient in present situation?
How the cold chain is maintained (while carrying blood from blood bank to nursing home/hosp.
Is there any blood storage equipment blood bank refrigerator available with nursing home/hosp YesNo
If blood unit is not utilized, (some times) discarded? how it is
Whether blood components are utilized at you nursing home/hosp mention names of blood components.
Do you regularly send the feed back about successful transfusion or adverse reaction to blood bank. YesNoSometimes
Do you wish to create storage facility at your hosp/nursing home? YesNo
if yes how soon
Do you need any technical support about blood transfusion / component usage/ blood conservation techniques. YesNo
Do you practice autologous blood transfusion/ intraoperative salvage techniques YesNo
Do you have computer & internet facility. YesNo
Name
Tel. Office/Hospital
Tel. Residential
Fax
Mobile
Email
Password
Website
District Ahmed nagarAkolaAmravatiAurangabadBeedBhandaraBuldhanaChandrapurDhuleGadchiroliGondiaHingoliJalgaonJalnaKolhapurLaturMumbaiNagpurNandedNandurbarNasikOsmanabadParbhaniPuneRaigadRatnagiriSangliSataraSindhudurgaSolapurThaneWardhaWashimYavatmal
Circle Ahmed nagarAkolaAmravatiAurangabadBeedBhandaraBuldhanaChandrapurDhuleGadchiroliGondiaHingoliJalgaonJalnaKolhapurLaturMumbaiNagpurNandedNandurbarNasikOsmanabadParbhaniPuneRaigadRatnagiriSangliSataraSindhudurgaSolapurThaneWardhaWashimYavatmal
