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PAGES
About
Services
Training Courses
Online Report Cord Blood
DEPARTMENTS
Phlebotomy Clinic
See a Specialist
Diagnostic Centre
CONTACT
Contact us
PAYMENTS
Online Reports
Home
Online Reports
Online Reports on Cord blood collections
Procurement Form
Phlebotomist Name
*
Phlebotomist ID
Client's Name
*
Customer ID or Kit Number
*
Customer ID (if twins)
Cell Bank
Did you verify ID?
Yes
No
Due Date
Date of Collection
Hospital or place of collection
Timings
Time of first contact
Time you left home
Time you arrived at site
Time of birth (baby 1)
Time of birth (baby 2)
Time placenta born
Time you received the placenta
Time you left the site
Delivery details
Mode of delivery of the baby
Normal vaginal delivery (NVD)
Instrumental delivery
Planned C-Section
Emergency C-Section
Mode of delivery of the placenta
Managed (Normal)
Physiological 3rd stage
With delayed Clamping
3rd stage + delayed clamping
Extracted in theatre
Baby's Gender (baby 1)
Male
Female
Baby's Gender (baby 2)
Male
Female
No. of Birth
First baby
Second baby
Third baby
No. of babies delivered
Singleton
Twins
Triplets
Collection Information
Where did the collection take place?
Sluice Room
Delivery Room
Theatre
Home birth
Did you obtain Consent?
Yes
No
Was the collection Kit intact?
Yes
No
Method of collection:
Ex-Uterus
En-Uterus
Did you collect Cord Blood?
Yes
No
It was collected by consultant
How much cord blood was collected? (Baby 1)
Nothing (Please explain why in the comments box)
Very little (Please explain why in the comments box)
1/4 bag full
1/3 bag full
1/2 bag full
more than 1/2 bag full
How much cord blood was collected? (Baby 2)
Nothing (Please explain why in the comments box)
Very little (Please explain why in the comments box)
1/4 bag full
1/3 bag full
1/2 bag full
More than 1/2 bag full
Did you collect Cord Tissue? (Baby 1)
Yes
No
Did you collect Cord Tissue? (Baby 2)
Yes
No
The Cord was:
Normal
Very short
Damaged
White and empty
Unclamped
Thin
Thick
Thick & Jelly like
Knotted
Clotted
Was the placenta intact?
Yes
No
Was there any delayed cord clamping?
Yes
No
Had anyone taken samples from the placenta before you?
Yes
No
The Placenta was:
Small
Normal
Large
Damaged
Meconium stained
Calcified
Did you take a picture from the placenta and the cord?
Yes
No
File Upload
File Upload
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Did you take the maternal blood?
Yes
Yes, taken by medical team
No, it will be taken later
No, it was already taken
Could you identify any risks?
Yes
No
Was the premises safe for you to perform the collection?
Yes
No
Were the staff friendly to you?
Yes
No
After completing the collection did you hand the kit back to the client or her Partner?
Yes
No
Any further comments?
Verification
Please enter any two digits
*
Example: 12
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