CBBS Emergency Communications Form

Message Routine ___ Date: Sent by:

No. Priority ___

Emergency ___ Time: Received by:

To:                                                Phone:

From:                                            Phone:

Blood / Blood Components Requested

No. Units Needed     Type & Rh     Components    Apheresis

Transportation Mode

Airline:               Fed Ex:                Bus:

Dep. Date:          Time:                  Tracking No.:

Arr. Date:           Time:                  No. of Boxes:

Comments:

Authorized Blood Bank                             Date Rec'd           Time Rec'd               Representative

Message Continued:

END

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