New Jersey Department of Health

Clinical Laboratory Improvement Services

PO Box 361

Trenton, NJ 08625-0361

BLOOD BANK ANNUAL STATISTICS

(Out of Hospital and “Emergency Only” Transfusion 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. For a response of zero, please indicate as such. Please retain a copy for your files. If you have any questions or if you need an extension for returning the report form, please contact the Clinical Laboratory Improvement Service, Blood Bank Unit, at 609-406-6829.

A.	SOURCES OF SUPPLY
Name of Source Blood Bank(s) or Transfusion Service(s) you obtained blood and blood components from:
1.
2.
3.
B.	USAGE	Received	Transfused
1.	Packed Red Blood Cells
2.	Platelets (Single Donor)
3.	Platelets (Random)
4.	Fresh Frozen Plasma
5.	Other
C.	MISCELLANEOUS
1.	Number of Suspected Transfusion Reactions detected:
-If any, specify the type of reaction(s):
-If any, did you notify the source blood bank?	Yes No
-Name of Source Blood Bank:
Name of Medical Director (Print)

Signature of Medical Director	Date

CL-8

JUL 12

CL-8, Blood Bank Annual Statistics

CL-8, blood bank, transfusion facilities, CLIS, statistics, annual report

Ewhite

2011-05-17

NJDOH