New Jersey Department of Health

Clinical Laboratory Improvement Services

PO Box 361

Trenton, NJ 08625-0361

BLOOD BANK ANNUAL STATISTICS

(Perioperative Autologous Blood Collection and Administration Facilities)

Name of Facility

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 Intraoperative Autologous Blood collections performed in New Jersey:
2.	Number of Postoperative Autologous Blood collections performed in New Jersey:
3	Number of Acute Normovolemic Hemodilution procedures performed in New Jersey:
4.	Number of Platelet Rich Plasma Gel procedures performed in New Jersey:
5	Attach a list of facilities in New Jersey where the above procedures were performed.

Name of Medical Director (Print)

Signature of Medical Director	Date

CL-14

JUL 12

CL-14, Blood Bank Annual Statistics, Perioperative

CL-14, blood bank, Perioperative, CLIS, statistics, annual report, autologous, blood collection,

Ewhite

2011-05-16

NJDOH