Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum (SCTIMST)

Existing SCTIMST Blood Donor

Name

:

Age

:

Sex

:

Male

Female

Residence Address

:

Residence State

:

Residence District

:

Office Address

:

Office State

:

Office District

:

Date of Birth
[dd-mm-yyyy]

:

Mobile No

:

Email

:

Last donation Date
[dd-mm-yyyy]

:

Planned Donation Date and Time
[dd-mm-yyyy hh24:mi]

:

Special Occasion

:

Details if others

:

Enter Security Code

:

Organizer Name

:

Organizer Address

:

Contact Person Name

:

Contact Mobile No

:

Email

:

Number of Donors

:

Conveyance facility required (subject to availability , max 10 km one side)

:

Yes

No

Planned Donation Date and Time

:

[ A confirmation message will be sent from SCTIMST ]

Special Occasion

:

Details if others

:

Enter Security Code

:

Organizer Name

:

Organizer Address

:

Contact Person Name

:

Contact Mobile No

:

Email

:

Approximate Number of Donors

:

Planned Donation Date and Time for Starting Camp

:

[ A confirmation message will be sent from SCTIMST ]

Approximate Distance From Institute (in KM)

:

Special Occasion

:

Details if others

:

Requirement

:

Height adjustable bed / couches / table(min 3 ft wide) 4 Nos

-

Yes

Table 4 Nos

-

Yes

Chairs (for Blood bank team) 10 Nos

-

Yes

Chairs (for donors) 25 Nos

-

Yes

Hand washing facility

-

Yes

Toilet

-

Yes

Power supply

-

Yes

A/C Hall

-

Yes

Fan / Pedestal Fans

-

Yes

Enter Security Code

:

Book Blood Donation