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Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
Application for Authority to Operate a Blood Collecting Unit (BCU)/ Blood Station
(BS)
Classification According to
Ownership : [ / ] Government [ ] Private
Acknowledgement
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
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same
IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2018.
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
III. List all Blood Collection Units/ Blood Stations supervised/ headed or associated with:
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
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
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
Revision:01
12/03/2014
Page 4 of 5
List of Equipment3
Name of BCU/ BS : COTABATO SANITARIUM
Address of BCU/ BS : Brgy. Ungap, Sultan Kudarat, Maguindanao
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
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
Page 5 of 5