Printable Forms

California Central Coast customers click here for a list of forms.

These are the forms currently available online. Click on the link to download a PDF or fillable Word document of the form. If you do not see the form you need or the link is inactive, contact your local blood center.

Transfer Document (BS 5150) – Used to return components to United Blood Services 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.

Emergency Release Document (BS 5341) – A physician, hospital or other medical facility uses the BS 5341, Emergency Release Document, to ask United Blood Services to issue whole blood and blood components before all the required laboratory testing has been completed. Such emergency releases require the approval of a United Blood Services 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 United Blood Services for sign off.

Special Order Form (BS 129S) – This form is used 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.)

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 (BS 962) –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.

Inspection Checklist for products stored at 20-24°C (BS 983A)
Inspection Checklist for refrigerated storage units (BS 983B)
Inspection Checklist for frozen component storage (BS 983C)