New Jersey Department of Health

BLOOD BANK PERSONNEL QUALIFICATION APPRAISAL

An individual employed in a blood bank as director, medical director, general supervisor, technical supervisor, technologist, phlebotomy supervisor, transfusionist, phlebotomist or technician, must establish his/her qualifications under P.L. 1963, Chapter 33, New Jersey Blood Bank Licensing Act. The Program needs the following information to determine whether the employer listed in Item 3 meets the requirements for qualified personnel. Authority to collect the information is given in Chapter 8 of the New Jersey State Sanitary Code (P.L. 1963, Chapter 33, New Jersey Blood Bank Licensing Act). Your response is voluntary; however, failure to furnish the requested information may result in the facility not being licensed or relicensed by the Department. If you do furnish the information, it will be used for:

(1)	routine administrative processes carried out in accordance with established regulations and published notices of systems of records, and

(2)	disclosures expressly permitted by the Privacy Act without the individual's consent, e.g., to the Bureau of the Census. The information will not be released to any persons or organizations outside of official administrative channels unless the individual specifically requests in writing that such disclosures be made (Privacy Act of 1974 - Public Law 93-579).

Verification of degree, diploma, board certification, etc., may be requested.

If assistance is needed, contact the Clinical Laboratory Improvement Service, Blood Bank Unit, at 609-406-6829.
1.	Name (Last, First, Middle)

2.	Maiden Name (if Married)

Mailing Address

City	State	Zip Code

3.	Name of Present Employer

Address

City	State	Zip Code

4.	Employment Work Arrangements

Full Time Part Time Call or Call Back Hours Per Week	5.	Shift

Day Evening Night
6.	Positions Currently Held in Laboratory

Blood Bank Director/Co-Director	Technical Supervisor	Transfusionist

General Supervisor	Technologist	Medical History Interviewer

General Laboratory Supervisor	Phlebotomist	Trainee

Phlebotomy Supervisor	Technician
7a.	High School Graduate or Equivalent

Yes No
College, University or Other Schools Attended
7b. Name and Address

of Institution	From	To	Major	Degree, Diploma or Certificate	Conferred
Mo.	Yr.	Mo.	Yr.
Mo.	Yr.

Name (Last, First, Middle)

8. Blood Bank or Transfusion Related Training

(Training fulfilling or partially fulfilling a Degree, Diploma, or Certificate requirement listed in Item 7b.)
Name and Address of Institution	Attended	Program Title	Degree, Diploma or Certificate	Conferred
From	To
Mo.	Yr.
9. License, Certification or Registration

[Include Cardiopulmonary Resuscitation Certification with Documentation (if applicable)]
Name of Granting Agency	Licensure/Certification

or Registration Title	Granted	License, Certificate, or Registration No.	MD/DO

(X) if Only

Brd Eligible
Mo.	Yr.
10. Proficiency Examinations- Department of Health and Human Services
Type of Examination	Passed	Identification

Number
Mo.	Yr.
Technologist
Director
11. Blood Bank or Transfusion-Related Experience

(Begin with earliest employment and continue through present employment. Any gaps in employment will be assumed to be unrelated experience.)
Name and Address

of Blood Bank or Institution	Period Employed	Position Held

(Indicate position(s) as shown in Item 6.)
From	To
Mo.	Yr.	Mo.	Yr.

Name (Last, First, Middle)

12. Remarks

(Add information pertinent to your education, training, employment, etc., not included above.)

- READ THE FOLLOWING CAREFULLY BEFORE SIGNING -

Statements or Entries Generally: Whoever, in any matter within the jurisdiction of any department or agency of the State of New Jersey knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes false, fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statements or entry, shall be subject to a penalty of not less than $100 or more than $1000 for each violation (N.J.S.A. 2A:58-1 et seq.).
CERTIFICATION: I CERTIFY that all of the statements made in this form are true, complete and correct to the best of my knowledge and belief and are made in good faith.
13. Signature of Applicant (Sign in Ink)	Date
CERTIFICATION: I CERTIFY that all of the statements made in this form are true, complete and correct to the best of my knowledge and believe and are made in good faith.
14. Signature of Current Blood Bank Director (Sign in Ink)	Date

FOR STATE USE ONLY
Name of Person in Item 1
15a.	Meets State Licensure Requirements (if applicable) as:

Director	Technical Supervisor	Technologist

Medical Director	Phlebotomy Supervisor	Phlebotomist

General Supervisor	Technician	Transfusionist

15b.	Does not quality as ___________________________________________________________________________.

Explain in Remarks Section the position(s) in which individual functions or proposes to, but does not qualify.
16. Reviewer Remarks
17. State Agency Reviewer	Date

BLOOD BANK PERSONNEL QUALIFICATION APPRAISAL

(Continued)

CL-40

JUL 12	Page 3 of 3 Pages.

JUL 12	Page 1 of 3 Pages.

CL-40, Blood Bank Personnel Qualification Appraisal

CL-40, CLIS, clinical lab improvement, blood bank, personnel, qualification, appriasal, employee, laboratory

ewhite

2001-04-19

NJDOH