Affix Patient Label Here

Patient Name

HID

Birth date

	Portable Refrigerator Response Log	

Fridge #

	Return Time:	Responding TSL Tech(s):	2nd TSL Tech/Time	
	  Approx. Age:	Clinical trial:      No
                         ATLAS         	 Gender: (circle)
 Male   /    Female 	
Location	MTP activated?
(circle)   Yes / No	Date/Time MTP activated:	Response Date & Time: 	

Date/Time Sample Drawn: ____________    //    Released by: _________________Date/Time: ________

Red Blood Cells	
Unit Number:	Date/Time Removed 	First Initial/Last Name
Visual Inspect OK	Date/Time Returned 
to Refrigerator	Returned to TSL Inventory                              Time/Date	Issued in SQ   TSL Tech Time/Date	

							

							

PLASMA							

							

Platelet

Clinical Care Staff Notified: __________________________           Notified by (TSL Tech): _______________________

Two Person Verification at Issue.  Visual Inspection at time of issue OK.
TECH ID: ________           TECH ID: _________
Issued by: _______________