CMC VELLORE EQAS–TRANSFUSIONMEDICINE MODULE

Transfusion Medicine Module Program Plan and Subscription Schedule 2017

PIN NUMBER: (For existing Participants only)

If you are a LABORATORY and wish to participate in
Blood grouping and typing exercises ONLY / Select Program A
Blood grouping and typing, Direct Coombs and Indirect Coombs Test / Select Program B
If you are a BLOODBANK and wish to participate in
Blood grouping and typing, Direct Coombs & Indirect Coombs Test, Compatibility Test / Select Program C
Blood grouping and typing , Direct Coombs & Indirect Coombs Test, Compatibility Testing , Antibody Screening & Antibody Identification / Select Program D
Transfusion Transmissible Infections Screen Module (serology – HIV, HBV, HCV, Syphilis and malaria –smear) / Select Program E

* IMPORTANT: If you do not participate in any of the individual parameters in any program, please do not tick the option. You will be evaluated and marked for all selected options. With Effect from 2017, we will be liable for Service Tax for all our EQA schemes.

Program / Parameters
(You should tick only the parameters you actually perform and wish to be evaluated for) / Tick (√) to Indicate Participation / Pricing / My Cost
Laboratories / Program A / Blood Grouping and Typing / Program Rs. 1800.00
OR
Program B / Blood Grouping and Typing / Program Rs. 2300.00
Direct Coombs and Indirect Coombs test
OR
Blood Banks / Program C / Blood Grouping and Typing / Program Rs. 2400.00
Direct Coombs and Indirect Coombs test
Compatibility test
OR
Program D / Blood Grouping and Typing / Program Rs. 3000.00
Direct Coombs and Indirect Coombs test
Compatibility test
Antibody Screening
Antibody Identification
Program E / Transfusion Transmissible Infections Screen Module (serology – HIV, HBV, HCV, Syphilis and malaria –smear) / Program Rs. 3000.00
Total Charge for blood Banks (C+E) or (D+E)

This form is to be returned along with yourregistrationpapersfor2017.Please retain a photocopy for your records. Payment will accepted only as Demand Draft favoring “The Treasurer CMC Vellore Association ( CMC EQAS)”

Name: / Signature
Date / Seal:
Effective: 01/12/2016 / Version 2.0 / Pricing Schedule 2017 / 1/1