Republic of the Philippines

Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU

Application for Authority to Operate a Blood Collecting Unit (BCU)/ Blood Station (BS)

Name of BCU/ BS :___________________________________________________

Address of BCU/ BS :___________________________________________________
No. & Street Barangay
_____________________________________
City/ Municipality Province Region
Telephone/ Fax No. :___________________________________________________

Head of the BCU/ BS :___________________________________________________

Name of Owner :___________________________________________________

Contact Number :___________________________________________________

Classification According to
Ownership : [ ] Government [ ] Private

Institutional Character : [ ] Hospital Based [ ] Non-hospital Based

Service Capability : [ ] BCU [ ] BS

Status of Application : [ ] Initial [ ] Renewal

License No. ________________
Date Issued ________________
Expiry Date ________________

Checklist of Application Documents

Please tick () the appropriate boxes under column B or C. Shaded Items are not required.
A B C
Documents For Initial For Renewal
1. Notarized Application for Authority to Operate a BCU/ BS (this form)
Submit
2. List of Personnel (attached form)
changes only
3. Photocopies of the following:
3.1. Proof of qualification of the medical and paramedical staff
Valid PRC ID
Specialty Board Certificate of the medical staff
Certificate of Training/ Record of Work Experience
3.2. Proof of employment of the medical, paramedical and administrative staff
Submit
4. List of Equipment/ Instrument (attached form)
changes only
5. Health Facility Geographic Form (Location Map)
Submit
6. Floor Layout
changes only
7. SEC/ DTI Registration (for private BCU/ BS) OR
Issuance or Board Resolution (for government BCU/ BS)
Submit
8. Quality Manual of BCU/ BS
changes only
9. NVBSP Annual Blood Report
10. Certificate of Inclusion in the Regional Blood Services Network approved by the
identified Lead Blood Center in the region
Form-BSF-ATO-A
Revision:01
12/03/2014
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 Acknowledgement

REPUBLIC OF THE PHILIPPINES )

CITY/ MUNICIPALITY OF ______________ ) S.S.

I, ______________________________, ____________, of legal age, __________, a resident of

Name Civil Status Age
___________________________________________, after having been sworn in accordance with law hereby depose
Address
and say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and the

attached documents required for the licensure and regulation of blood service facilities in the Philippines pursuant to

Administrative Order No. 2008-0008 Rules and Regulations Governing the Regulation of Blood Service Facilities.

_________________________
Signature

Before me, this _________day of ______________ 20 in the City/ Municipality of ________________,

Philippines, personally appeared

Owner Community Tax Number Issued at/ on

_______________________________ _________________________ _________________________

known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same

is their free act and deed.

IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 20

Doc. No. _____________________ NOTARY PUBLIC

Page No. ____________________ My Commission Expires
Book No. ____________________ Dec. 31, _______
Series of ____________________

Form-BSF-ATO-A
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12/03/2014
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 APPLICATION AS HEAD OF BLOOD COLLECTING UNIT/ BLOOD STATION

The Director
Health Facilities and Services Regulatory Bureau/DOH-Regional Office
DOH Manila/ Regional Office

Sir,

In compliance with the requirements of Republic Act (RA) No. 7719 and Administrative
Order (AO) No. 2008-0008, I have the honor to apply as head of:

_________________________________________
Name of Blood Collecting Unit/ Blood Station
_________________________________________
Address of Blood Collecting Unit/ Blood Station

I. Name of Applicant: ______________________________________________________

Landline No.: ________________________ Mobile No.: _______________________
Address: ______________________________________________________________

II. Education and Training (Use additional sheets if necessary):

Medical School/ Institution _____________________________________________
Inclusive Dates/ Year Graduated ________________________________________

Specialty Board Date Certified Training Institution

PBP 1 Anatomic
Pathology
PBP Clinical Pathology
PBP Anatomic and
Clinical Pathology
PSHBT2
Others: Specify

III. List all Blood Collection Units/ Blood Stations supervised/ headed or associated with:

Name and Address of BCU/ BS Working Time Work Schedule

A. As Head
B. As Associate

I hereby certify that the foregoing statements are true. I assume full responsibility that the
operation of the Blood Collection Unit/ Blood Station is in accordance with the Rules and
Regulations pursuant to RA 7719 and AO No. 2008-0008.

______________________________
Signature over Printed Name

Date

1 PBP Philippine Board of Pathology

2 PSHBT Philippine Society for Hematology and Blood Transfusion
Form-BCU_BS-Head-A
Revision:01
12/03/2014
 List of Personnel

Name of BCU/ BS : _______________________________________________________________________________________

Address of BCU/ BS : _______________________________________________________________________________________

PRC Reg. No. Valid

Name Designation/ Position Highest Educational Attainment Signature
(If applicable) From To

Form-BSF-ATO-A
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12/03/2014
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 List of Equipment3

Name of BCU/ BS : _______________________________________________________________________________________

Address of BCU/ BS : _______________________________________________________________________________________

Brand Name & Model Serial No. Quantity Date of Purchase

3 Equipment shall be functional and present in the Blood Collection Unit/ Blood Station applying for Authority to Operate. Form-BSF-ATO-A
Revision:01
12/03/2014
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