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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 : COTABATO SANITARIUM


Address of BCU/ BS : Brgy. Ungap,
No. & Street Barangay
Sultan Kudarat Maguindanao
City/ Municipality Province Region
Telephone/ Fax No. : 064-429-0082

Head of the BCU/ BS : SHERJAN P. KALIM, MD, DPSP

Name of Owner : IBRAHIM V. PANGATO, JR, MD, DDM, FPMSI


Contact Number : 064-429-0082

Classification According to
Ownership : [ / ] Government [ ] Private

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

Service Capability : [ ] BCU [ / ] BS

Status of Application : [ ] Initial [ / ] Renewal


License No.:12-0006-17-140-HI-1
Date Issued: January 1, 2018
Expiry Date:December 31, 2018

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) /
2. List of Personnel (attached form) /
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
/
4. List of Equipment/ Instrument (attached form) /
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)
A B C
Documents For Initial For Renewal
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, IBRAHIM V. PANGATO, JR, Married, of legal age, 48, a


Name Civil Status Age
resident of 214A, Penaprancia Village, RH II, Cotabato City, after having been sworn in accordance with law hereby
Address
depose 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

IBRAHIM V. PANGATO, JR 11298058 Cotabato City/ 01-31-2018

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 _______________ 2018.

Doc. No.______________________ NOTARY PUBLIC


Page No.______________________ My Commission Expires
Book No.______________________ Dec. 31, _______
Series of ____________________
Form-BSF-ATO-A
Revision:01
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:

COTABATO SANITARIUM
Name of Blood Collecting Unit/ Blood Station
Brgy. Ungap, Sultan Kudarat, Maguindanao
Address of Blood Collecting Unit/ Blood Station

I. Name of Applicant: : SHERJAN P. KALIM, MD, DPSP


Landline No.: None Mobile No.: 0917 971 3201
Address: 35 Don Abelardo St., Cotabato City

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


Medical School/ Institution: University of Santo Tomas
Inclusive Dates/ Year Graduated: 2003

Specialty Board Date Certified Training Institution


1
PBP Anatomic
Pathology
PBP Clinical Pathology
PBP Anatomic and April 23, 2009 Philippine General Hospital
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 at CRMC, Cotabato City 8am – 5pm 8am – 5pm

1
PBP – Philippine Board of Pathology
2
PSHBT – Philippine Society for Hematology and Blood Transfusion
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.

SHERJAN P. KALIM
Signature over Printed Name

Date

Form-BCU_BS-Head-A
Revision:01
12/03/2014
List of Personnel

Name of BCU/ BS : COTABATO SANITARIUM


Address of BCU/ BS : Brgy. Ungap, Sultan Kudarat, Maguindanao

PRC Reg. No. Valid


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

SHERJAN P. KALIM, MD, DPSP Pathologist Doctor of Medicine 0103706 07/14/2016 08/27/2019

ALBARAH S. MEDITAR, RMT Chief Medical Technologist College Graduate 0054965 11/22/2018 11/21/2021

SOFIA S. WAHAB, RMT Assistant Chief Med. Tech. College Graduate 0031945 02/15/2017 03/07/2020

MICHELLE O. OCSIO, RMT Medical Technologist I College Graduate 0043500 02/15/2017 03/10/2020
ALIANNA ARNICA A.
Medical Technologist I College Graduate 0067005
MAMBATAO, RMT
NARISA U. OMAR, RMT Medical Technologist I College Graduate 0064013 12/14/2016 04/30/2020

NORMIA A. TAHIR, RMT Medical Technologist I College Graduate 0056445 02/15/2017 05/10/2020

HILDA Y. DIMA Laboratory Technician I College Graduate N/A N/A N/A

BAI MEXICAN C. MASABPI Laboratory Technician I College Graduate N/A N/A N/A
MARGUIANA A. DALAMBAN,
Medical Technologist College Graduate 0075674 09/19/2016 12/03/2019
RMT

Form-BSF-ATO-A
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12/03/2014
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List of Equipment3
Name of BCU/ BS : COTABATO SANITARIUM
Address of BCU/ BS : Brgy. Ungap, Sultan Kudarat, Maguindanao

Brand Name & Model Serial No. Quantity Date of Purchase

Centrifuge: Digisystem/DSC-156 DSC156MF 1 10/14/1996


Centrifuge: Digisystem/DSC-154 9701205-54 1 09/14/1998
Oven: Memmert/UM 100 UM 100 1 12/24/1998
Microscope: Olympus/CX-21 OA82326 1 11/18/2009
Microscope: Olympus/CX-21 OA82529 1 04/13/2015
BB Ref.: Panasonic/MBR-704GR-PK 12010005 1 03/10/2015
Water Bath: Biobase/SX-1L2H BK2015011 1 12/01/2015
Microcentri.: Digisystem/DSC-100MH-1 14120502 1 12/06/2016
Chemistry: StatFax/4500 4500-4334 1 12/14/2016 (Tie up)
Aircon.: Koppel/KWR-09RBC 16004AC011 1 04/04/2017
Med. Ref.: Biobase/BXC-V20M 2GO5F 1 10/2017
Cepheid/GeneXpert 815277 1 12/2017
Biomed.Freezer: Panasonic/MDF-U334 13100399 1 2017
Immuno.: Biomerieux/Mini Vidas IVD5211726 1 4/2018
Grifols/ DG Spin 320-0006251 1 4/2018
Grifols/ DG Therm 319-0005282 1 4/2018

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
List of Equipment3 Page 5 of 5
Name of BCU/ BS : COTABATO SANITARIUM
Address of BCU/ BS : Brgy. Ungap, Sultan Kudarat, Maguindanao

Brand Name & Model Serial No. Quantity Date of Purchase

Electrolytes: Horron/H900 E28095418 1 8/14/2018


Hema.: Mindray/BC-5100 RE-18100378 1 8/14/2018
Hema.: Medicalsystem/MS-H650 MSH65020180426010 1 8/23/2018

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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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