Republic of the Philippines
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
Application for Authority to Operate a Blood Collecting Unit (BCU)/ Blood Station
(BS)
Name of BCU/ BS : COTABATO SANITARIUM
Address of BCU/ BS : Brgy. Ungap,
No. & Street Barangay
Sultan Kudarat Maguindanao
City/ Municipality Province Region
Telephone/ Fax No. : 064-429-0082
Head of the BCU/ BS : SHERJAN P. KALIM, MD, DPSP
Name of Owner : IBRAHIM V. PANGATO, JR, MD, DDM, FPMSI
Contact Number : 064-429-0082
Classification According to
Ownership : [ / ] Government [ ] Private
Institutional Character : [ / ] Hospital Based [ ] Non-hospital Based
Service Capability : [ ] BCU [ / ] BS
Status of Application : [ ] Initial [ / ] Renewal
License No.:12-0006-17-140-HI-1
Date Issued: January 1, 2018
Expiry Date:December 31, 2018
Checklist of Application Documents
Please tick () the appropriate boxes under column B or C. Shaded Items are not required.
A B C
Documents For Initial For Renewal
1. Notarized Application for Authority to Operate a BCU/ BS (this form) /
2. List of Personnel (attached form) /
3. Photocopies of the following:
3.1. Proof of qualification of the medical and paramedical staff /
Valid PRC ID /
Specialty Board Certificate of the medical staff /
Certificate of Training/ Record of Work Experience
3.2. Proof of employment of the medical, paramedical and administrative staff
/
4. List of Equipment/ Instrument (attached form) /
5. Health Facility Geographic Form (Location Map) /
Submit
6. Floor Layout
changes only
7. SEC/ DTI Registration (for private BCU/ BS) OR
Issuance or Board Resolution (for government BCU/ BS)
A B C
Documents For Initial For Renewal
Submit
8. Quality Manual of BCU/ BS
changes only
9. NVBSP Annual Blood Report /
10. Certificate of Inclusion in the Regional Blood Services Network approved by the
identified Lead Blood Center in the region /
Form-BSF-ATO-A
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12/03/2014
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Acknowledgement
REPUBLIC OF THE PHILIPPINES )
CITY/ MUNICIPALITY OF _______________) S.S.
I, IBRAHIM V. PANGATO, JR, Married, of legal age, 48, a
Name Civil Status Age
resident of 214A, Penaprancia Village, RH II, Cotabato City, after having been sworn in accordance with law hereby
Address
depose and say that I am executing this affidavit to attest to the completeness and truth of the foregoing information and
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
Before me, this _________day of ______________ 20 in the City/ Municipality of ________________,
Philippines, personally appeared
Owner Community Tax Number Issued at/ on
IBRAHIM V. PANGATO, JR 11298058 Cotabato City/ 01-31-2018
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the same
is their free act and deed.
IN WITNESS WHEREOF, I have hereunto set my hands this _________day of _______________ 2018.
Doc. No.______________________ NOTARY PUBLIC
Page No.______________________ My Commission Expires
Book No.______________________ Dec. 31, _______
Series of ____________________
Form-BSF-ATO-A
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APPLICATION AS HEAD OF BLOOD COLLECTING UNIT/ BLOOD STATION
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
I. Name of Applicant: : SHERJAN P. KALIM, MD, DPSP
Landline No.: None Mobile No.: 0917 971 3201
Address: 35 Don Abelardo St., Cotabato City
II. Education and Training (Use additional sheets if necessary):
Medical School/ Institution: University of Santo Tomas
Inclusive Dates/ Year Graduated: 2003
Specialty Board Date Certified Training Institution
1
PBP Anatomic
Pathology
PBP Clinical Pathology
PBP Anatomic and April 23, 2009 Philippine General Hospital
Clinical Pathology
PSHBT2
Others: Specify
III. List all Blood Collection Units/ Blood Stations supervised/ headed or associated with:
Name and Address of BCU/ BS Working Time Work Schedule
A. As Head
B. As Associate at CRMC, Cotabato City 8am – 5pm 8am – 5pm
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
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12/03/2014
List of Personnel
Name of BCU/ BS : COTABATO SANITARIUM
Address of BCU/ BS : Brgy. Ungap, Sultan Kudarat, Maguindanao
PRC Reg. No. Valid
Name Designation/ Position Highest Educational Attainment Signature
(If applicable) From To
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
HILDA Y. DIMA Laboratory Technician I College Graduate N/A N/A N/A
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
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List of Equipment3
Name of BCU/ BS : COTABATO SANITARIUM
Address of BCU/ BS : Brgy. Ungap, Sultan Kudarat, Maguindanao
Brand Name & Model Serial No. Quantity Date of Purchase
Centrifuge: Digisystem/DSC-156 DSC156MF 1 10/14/1996
Centrifuge: Digisystem/DSC-154 9701205-54 1 09/14/1998
Oven: Memmert/UM 100 UM 100 1 12/24/1998
Microscope: Olympus/CX-21 OA82326 1 11/18/2009
Microscope: Olympus/CX-21 OA82529 1 04/13/2015
BB Ref.: Panasonic/MBR-704GR-PK 12010005 1 03/10/2015
Water Bath: Biobase/SX-1L2H BK2015011 1 12/01/2015
Microcentri.: Digisystem/DSC-100MH-1 14120502 1 12/06/2016
Chemistry: StatFax/4500 4500-4334 1 12/14/2016 (Tie up)
Aircon.: Koppel/KWR-09RBC 16004AC011 1 04/04/2017
Med. Ref.: Biobase/BXC-V20M 2GO5F 1 10/2017
Cepheid/GeneXpert 815277 1 12/2017
Biomed.Freezer: Panasonic/MDF-U334 13100399 1 2017
Immuno.: Biomerieux/Mini Vidas IVD5211726 1 4/2018
Grifols/ DG Spin 320-0006251 1 4/2018
Grifols/ DG Therm 319-0005282 1 4/2018
3
Equipment shall be functional and present in the Blood Collection Unit/ Blood Station applying for Authority to Operate. Form-BSF-ATO-A
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List of Equipment3 Page 5 of 5
Name of BCU/ BS : COTABATO SANITARIUM
Address of BCU/ BS : Brgy. Ungap, Sultan Kudarat, Maguindanao
Brand Name & Model Serial No. Quantity Date of Purchase
Electrolytes: Horron/H900 E28095418 1 8/14/2018
Hema.: Mindray/BC-5100 RE-18100378 1 8/14/2018
Hema.: Medicalsystem/MS-H650 MSH65020180426010 1 8/23/2018
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Equipment shall be functional and present in the Blood Collection Unit/ Blood Station applying for Authority to Operate. Form-BSF-ATO-A
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