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Use to report blood shipments. Reference: FM 8-10-5.

LINE 1 — DATE AND TIME______________________________(DTG)

LINE 2 — UNIT________________________________________(Unit Making Report)

LINE 3 — ACTIVITY____________________________________(Reporting Unit’s Activity

Code Letter:
A = Joint Blood Program Office
B= Area Joint Blood Program Office
C = Armed Services Whole Blood Processing Laboratory
D = Blood Donor Center
E = Blood Products Depot
F = Blood Transshipment Center
G = Blood Supply Unit
H = Medical Treatment Element
I = Naval Vessel)

LINE 4 — LOCATION___________________________________(UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator)

LINE 5 — RENDEZVOUS________________________________(NAVAL VESSELS ONLY: UTM or Six-Digit Grid Coordinate With MGRS Grid Zone Designator for Delivery of Blood Products)

LINE 6 — ARRIVAL_____________________________________(NAVAL VESSELS ONLY (Hospital Ship): Estimated DTG at the Projected Location)

LINE 7 — PRODUCT____________________________________(Brevity Code Letter of Blood Product Being Shipped:
J =Red Blood Cells
K =Whole Blood
L =Frozen Red Blood Cells
M =Fresh Frozen Plasma
N =Frozen Platelets)

LINE 8 — O POSITIVE__________________________________(Number of Units)

LINE 9 — O NEGATIVE_________________________________(Number of Units)

LINE 10 — A POSITIVE_________________________________(Number of Units)

LINE 11 — A NEGATIVE________________________________(Number of Units)

LINE 12 — B POSITIVE_________________________________(Number of Units)

LINE 13 — B NEGATIVE________________________________(Number of Units)

LINE 14 — AB POSITIVE________________________________(Number of Units)

LINE 15 — AB NEGATIVE_______________________________(Number of Units)

LINE 16 — TOTAL_____________________________________(Total Number of Units of Blood Product Being Shipped)

**Repeat lines 7 through 16 as a group when shipping more than one blood product. Assign sequential line numbers to succeeding iterations; for example, first iteration 7 through 16; second iteration 7a through 16a; third iteration 7b through 16b; and so on.

LINE 17 — CONTROL___________________________________(Airbill Number or Transportation Control Number (TCN))

LINE 18 — MISSION____________________________________(Airline and Flight Number or Mission Number Assigned at the Shipment’s Origin)

LINE 19 — ARRIVAL____________________________________(Estimated DTG of Shipment’s Arrival at Destination)

LINE 20 — BOXES______________________________________(Number of Boxes in Shipment)

LINE 21 — CONTACT___________________________________(Name of Shipper’s Point of Contact)

LINE 22 — PHONE _____________________________________(24-Hour Telephone Number of Shipper’s Point of Contact)

LINE 23 — NARRATIVE_________________________________(Free Text for Additional Information Required for Clarification of Report

LINE 24 — AUTHENTICATION___________________________(Report Authentication)

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