CENTER INFORMATION       CUSTOMER

Center Information:

     

     

     

Cost Center Location:

     

Print Customer Name:

     

Account Number:

     

Date:

     

Address:

     

City, State, Zip Code:

     

Donation Number

Component Code

ABO/Rh

Received Date

Expiration Date

Reason Code

Comments

Vitalant Approval
Yes or No
(Reason Denied)

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Vitalant HSD or Designee

Vitalant Finance

Incomplete Information: DIN number, Component Code, Reason Code, and/or Signature will delay the credit approval process. All forms must be legible.

Date Received:

Date Received:

Approved by:

Date Entered:

Print First Initial, Last Name

BS 162 #:

Sales Order #:

Customer’s Authorized Signature

Reason Codes Legend on back.

Reason Codes Legend

Code

Description

111

Damaged Bag: Provide detail of damage (bag broken, leaked, damaged, broke during thaw, etc.)

112

Defective Product: Provide detail of defect (product hemolyzed, clotted, discolored, etc.)

113

Out of Temp upon Receipt: Provide temperature of product received

114

Manufacturer Recall: Recall for manufacturing issues

115

Vitalant Initiated Event: Disposal at the hospital at the instruction of Vitalant - Provide reason supplied by Vitalant (form BS 5305C)

121

Short Date: Product received was short dated

122

Product not Returned: Provide reason for product not being returned  (advised to hold, excessive inventory, etc.)

123

Product not Rotated: Provide reason for product not being rotated  (per contract agreement; expired on hospital shelf, etc.)

131

Vitalant Error: Provide detail of error (product not requested, delayed shipping, wrong product, etc.)

132

Customer Order Error: Wrong product requested - Provided intended product code

133

Other: Provide explanation of request

NOTE: Comment required for all HWBO requests.