New Jersey Department of Health

Clinical Laboratory Improvement Service

PO Box 361

Trenton, NJ 08625-0361

BROKERS AND REAGENT MANUFACTURERS ‑ ANNUAL STATISTICAL DATA

Name of Blood Bank

County

Address

Name of Individual Completing Form

Telephone Number

Please furnish the following data for the report year and return to the above address, by the required date. Please retain a copy for your files. If assistance is needed, contact the Blood Bank Program of the Clinical Laboratory Improvement Service at 609-406-6829.
A. Source of Plasma Supply
Name	Address	Amount

(in Liters)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
Name of Blood Bank

A. Source of Plasma Supply, Continued
Name	Address	Amount

(in Liters)
q.
r.
s.
t.
u.
v.
B. Distribution of Plasma
Name	Address	Amount

(in Liters)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
C. Use of Plasma
a. Number of units used for in vitro diagnostic reagents and controls.
b. Number of units destroyed as unusable.
c. Number of units on hand, December 31.

Signature of Blood Bank Director	Date

BROKERS AND REAGENT MANUFACTURERS – ANNUAL STATISTICAL DATA

(Continued)

CL-50

JUL 12	Page 2 of 2 Pages.

JUL 12	Page 1 of 2 Pages.

CL-50, Brokers and Reagent Manufacturers, Annual Statistical Data

CL-50, CLIS, CL, clinical laboratory, blood bank, reagent manufacturers, brokers, statistics

EWhite

2001-04-19

NJDOH