New Jersey Department of Health

Clinical Laboratory Improvement Services

PO Box 361

Trenton, NJ 08625-0361

BLOOD BANK ANNUAL STATISTICS

(Hematopoietic Progenitor Cell Facilities)

Name of Blood Bank

CALENDAR YEAR

Street Address

County

City, State, Zip Code

Name of Individual Completing Form

Telephone Number

Please furnish the following data for the report year and return to the Department at the above address provided in the cover letter. If the response(s) is(are) zero, please indicate that as well. Please retain a copy for your files. If assistance is needed, contact the Clinical Laboratory Improvement Service, Blood Bank Unit, at 609-406-6829.

1.	Number of Hematopoietic Progenitor Cells collected in New Jersey:
2.	Number of Hematopoietic Progenitor Cells processed (from New Jersey collections only):
3	Number of Hematopoietic Progenitor Cells stored (from New Jersey collections only):
4.	Number of Hematopoietic Progenitor Cells collected in New Jersey used for transplantation:

Name of Medical Director (Print)

Signature of Medical Director	Date

CL-13

JUL 12

CL-13, Blood Bank Annual Statistics, Hematopoietic Progenitor Cell Facilities

CL-13, blood bank, Hematopoietic, Progenitor, CLIS, statistics, annual statistics

Ewhite

2011-05-16

NJDOH