WAIVER/BLOOD DONORS CONSENT I, ___________________________, am voluntarily giving my blood to SLU-NSTP through the Philippine Red Cross, without remuneration,

for the use of persons in need of this vital fluid without regard to rank, race, color, creed, religion, or political persuasion. I understand that all questions are pertinent for my safety and for the benefit of the medical patients who will undergo blood transfusion. I understand that my blood will be screened for malaria, syphilis, hepatitis B, hepatitis C and HIV. I authorize the Red Cross to inform me of the results of the screening test and to dispose of my blood donated in any way it may deem advisable for the benefit of suffering humanity. I shall not hold the University or its representatives liable for any untoward incident that may occur as a consequence of the blood donation. I certify that I am the person referred to in the above and that all the entries are read and well understood by me. I certify that I have, to the best of my knowledge, truthfully answered all the questions in this blood Donor Interview Sheet. __________________________________ Name and Signature of Donor Date:______________________ _________________________________ Name and signature of Parent/ Guardian Date:____________________________

Note: Please do not hesitate to ask question, if necessary. Please check: ( ) Own self/NSTP Student as blood donor ( ) Others as donor; Recruited by:____________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - WAIVER/BLOOD DONORS CONSENT

I, ___________________________, am voluntarily giving my blood to SLU-NSTP through the Philippine Red Cross, without remuneration, for the use of persons in need of this vital fluid without regard to rank, race, color, creed, religion, or political persuasion. I understand that all questions are pertinent for my safety and for the benefit of the medical patients who will undergo blood transfusion. I understand that my blood will be screened for malaria, syphilis, hepatitis B, hepatitis C and HIV. I authorize the Red Cross to inform me of the results of the screening test and to dispose of my blood donated in any way it may deem advisable for the benefit of suffering humanity. I shall not hold the University or its representatives liable for any untoward incident that may occur as a consequence of the blood donation. I certify that I am the person referred to in the above and that all the entries are read and well understood by me. I certify that I have, to the best of my knowledge, truthfully answered all the questions in this blood Donor Interview Sheet. __________________________________ Name and Signature of Donor Date:______________________ _________________________________ Name and signature of Parent/ Guardian Date:____________________________

Note: Please do not hesitate to ask question, if necessary. Please check: ( ) Own self/NSTP Student as blood donor ( ) Others as donor; Recruited by:____________________________

Endorsement Sheet

NATIONAL SERVICE TRAINING PROGRAM (NSTP) OFFICE

ST. LOUIS UNIVERSITY SCHOOL OF TEACHER EDUCATION

Date:_________________________

Philippine Red Cross _________________Chapter

Dear Sir/Maam: Greetings. Please accommodate ________________________________ for blood donation in your chapter as per your
(name

of blood donor)

request earlier for blood donors any blood type. Please record also the donation under our blood donation program with your institution. May we further request that the information below be accomplished and be provided our office. Please send this accomplished information back to us through the donor/bearer: 1. Status of donation/bleeding (pls. check): ___successful ____unsuccessful ____deferred _______________other remarks 2. Blood type: ____________ 3. Blood volume donated: _____________ 4. Date of donation: _______________Time of Donation: ______________ 5. Attending PRC Personnel: ___________________________________ Name and Signature Designation: __________________________ Thank you very much. Very respectfully, ____________________________________
Name and Signature of Project Supervising Instructor

Noted: Mr. Albert G. Guinguino Jr. NSTP Coordinator

To be accomplished by the NSTP Student:

Please check: ( ) Own self/NSTP Student as donor ( ) Others as donor; Recruited by:____________________________
PRC- Baguio Chapter is located along Harrison Road, beside Land Bank of the Philippines. PRC-Benguet Chapter is located at the back of Benguet General Hospital, km. 5 La Trinidad, Benguet.

For the Donor: Let this be properly accomplished by the attending PRC personnel. Submit NSTP copy at the NSTP office and SI copy to your Supervising Instructor for proper recording and keep your personal copy.

APOSTOLATE REMINDERS TO ENSURE SUCCESS OF APOSTOLATE AND SAFETY OF PARTICIPANTS 1. Blood donation must be voluntary. Encourage and do not force students or yourself to donate blood. 2. Always seek instruction from your Supervising Instructor. In case of conflict of instruction, students must consult/ clarify said instruction to their Supervising Instructor (SI) first before doing such. 3. Your apostolate is an official activity in the University. Hence, you are required to observe the Code of Discipline and other performance and behavioral guidelines specified in the SLU Student Manual and the NSTP Manual of procedures and guidelines. 4. Follow strictly approved apostolate schedules and itinerary. Changes therein should be approved by the Supervising Instructor first. 5. Be reminded that attendance, tardiness and absences are likewise monitored during the apostolate and concerned NSTP students are held accountable of their attendance, tardiness and absences. 6. Always work as a team. Unless approved by the SI, the least number of students allowed to work on a particular itinerary is two or one pair; no one is allowed to go on apostolate individually or just by him/herself. No loitering or leaving the area of apostolate without company and without the approval from the supervising instructor or the team leader. 7. Be reminded to keep proper documentation of your apostolate activities and other necessary related things. Take pictures of your apostolate before, during and after its implementation. 8. Be reminded to accomplish and turn in updated personal narrative report and activity time record with the Supervising Instructor weekly. 9. Always wear properly (visible at chest level) your SLU student and NSTP apostolate IDs while on apostolate. 10. Be dressed properly for the apostolate. Bring things that are needed during the apostolate. Avoid bringing unnecessary things that will disturb your attention and concentration. Dont bring valuables that are attractive to bad elements. Bring your cell phone (if you have) fully charged and loaded (for proper communication and emergency). 11. Always observe and practice safety and security provisions or precautions. 12. Be reminded of the preventions and safety precautions as specified in your waiver or guardians consent. 13. Always have an accessible contact number of the following who are near or close in the apostolate area: police, hospital, ambulance units, emergency medical service units like Red Cross and BEMs, apostolate host or partner, supervising instructor, NSTP Coordinator or other persons who could be of help during emergencies. 14. In case of emergency, potential or actual, stop ongoing activity and immediately secure yourself and contact the number/persons specified in item 13. Contact the most accessible entity but just the same, contact all the persons/entities specified in item 13 to be sure. If the Supervising Instructor is by the vicinity and he/she is accessible immediately, you can coordinate first with him/her. 15. Always bring snacks/meals/water, extra clothes and the medicine kit during all activities. 16. All plans and activities should be presented first and approved by the Supervising Instructor and the NSTP Coordinator before the actual performance of the activity. 17. As part of your NSTP Apostolate Requirement, the MNHA: Blood Services members are to encourage/scout volunteer blood donors to donate blood to Philippine Red Cross. 18. Apostolate members who are qualified to donate are strongly encouraged to donate their blood as a form of community service involvement. However, Blood Services members who are not qualified to donate may encourage/scout one donor who will donate blood to PRC. 19. Only those who donated blood with successful bleeding and with complete papers are counted/considered. Blood Donation member/recruited donor who failed to donate successfully due to some reasons are still required to complete the requirement. They are to look for another blood donor who is willing to donate. Be ready with your reserved blood donors in case you or your first blood donor did not successfully donate blood. 20. Be informed on the following qualifications of a blood donor: Strictly 18 years old and above weight: at least 110 lbs. (50 kgs.) No recent surgery No recent alcohol intake In good health (Persons with cancer, cardiac disease, severe lung disease, Hepa. B/C,HIV Infections, STD, chronic alcoholism are NOT allowed to donate blood ANYTIME) No ear or body piercing and tattooing No acute fever For ladies, no monthly period

21. Soon as you are ready to donate/had recruited blood donor, follow the following procedure: a. For NSTP Students as blood donors: write a letter addressed to the NSTP Coordinator (see format at the NSTP office) stating that you are willing to donate blood. Accomplish letter in four copies. You may photocopy the original one but signatures must be in original ink. Submit letter to your SI for assessment and for approval of the NSTP Coordinator. For Students with recruit blood donor: write a letter addressed to the NSTP Coordinator (see format at the NSTP Office) stating that you had recruited blood donor who is willing to donate blood. Submit letter to your SI for assessment and for approval of the NSTP Coordinator. b. Upon approval of the letter, secure Blood Donation Waiver at the Gonzaga photocopy center in four (4) copies or download a copy from the SLU NSTP Facebook. Accomplish the waiver properly and submit it to your SI. If you recruited a donor, then let them accomplish the waiver properly before submitting it to your SI. NO WAIVER, NO BLOOD DONATION (even if the blood donor is at legal age). c. Soon as youve accomplished the waiver, get Blood Donation Endorsement form- secure copy at the Gonzaga photocopy center in four (4) copies. Accomplish the form properly by writing your name and name of Supervising Instructor on the space provided. d. Let your endorsement form be signed by your respective Supervising Instructor and the NSTP Coordinator. Attach the Blood Donation waiver to the endorsement form. The papers are labeled as follows: 1 Student copy, 1 NSTP Office copy, 1 SI copy and 1 PRC copy (the PRC copy will be surrendered to them after the bleeding). e. Bring with you your endorsement sheet and waiver when going to PRC for the bloodletting. Make sure you have companion when you go to the PRC to donate or accompany your recruit donor to PRC for the blood donation. f. Follow schedule and assigned PRC Chapter for blood donation as follows: Schedule of Blood Donation Own self as Donor Others as Donor 1. Bandoc, Maureen May 10,11and 16, May 2,3,4,9,10, and Jane 2011 11, 2011 2. Cuanso, Donny May 12,13 and 14, May 5,6,7,12,13, Mark 2011 and 14,2011 3. Depayso, Beverly May 12,13 and 14, May 5,6,7,12,13, 2011 and 14,2011 4. Jamero, Dorothy May 12,13 and 14, May 2,3,4,9,10, and 2011 11, 2011 5. Palangyos, Randy May 12,13 and 14, May 5,6,7,12,13, 2011 and 14,2011 6. Sab-it, Inid May 12,13 and 14, May 2,3,4,9,10, and 2011 11, 2011 7. Soriano, Johnny May 12,13 and 14, May 5,6,7,12,13, 2011 and 14,2011 8. Tiongan, Jenefer May 12,13 and 14, May 2,3,4,9,10, and 2011 11, 2011 Name of SI Chapter Baguio Baguio Benguet Benguet Benguet Benguet Benguet Benguet

g. PRC-Baguio is located along Harrison Rd. before Land Bank while PRC-Benguet Chapter is located at the back of Benguet General Hospital, km. 5, La Trinidad, Benguet. h. After the blood donation, successful or not successful, report immediately to your Supervising Instructor. i. For Apostolate members with successful blood donation, submit to your SI the NSTP office copy and SI copy. Keep your personal copy for your reference later. j. For apostolate members with unsuccessful blood donation, report to SI to inform the matter. Look for another recruit and repeat procedures a-g until such requirement is met.

Prepared by: MRS. BEVERLY K. DEPAYSO Supervising Instructor MR. ALBERT G. GUINGUINO, JR. NSTP Coordinator