Affix Patient Label Here

	Portable Refrigerator Log	

Patient Name:

	Return Time:	Responding TSL Tech(s):
 	Patient Location
 	
Hospital ID#:
	Reason for Fridge:
	Fridge #
 	Response Date & Time:

Allocated Blood Products		Completed by TSL			      Completed by Clinical Staff
Unit Number	Product Type	Patient Type/Rh	Unit
Type/Rh	DATE/TIME
Removed	First Initial/Last Name	DATE/TIME Returned	First Initial/Last Name	
	RBCs	Thawed Plasma							

									

									

									

Clinical Care Staff notified: (signature)       ___________________________	

Notified by:  (TSL Tech)    _________________