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I certify that the blood products listed have been properly maintained
Temperature upon receipt: ___________ degrees C
Container and contents: __ Satisfactory __ Unsatisfactory
Received date/time: ________________ Signature: ________________
in accordance with the Code of Federal Regulations while in storage at
this institution. Each unit is nonreactive for anti-HIV 1/2, HBsAg,
anti-HCV(2.0),HBcAB, anti-HTLV 1, and RPR by FDA required tests. ALT levels are within established limits. Components were inspected when packed
for shipment and found to be satisfactory in color and appearance.
_____________________________ ____________________________
Signature Date//time packed
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