New Jersey Department of Health

Clinical Laboratory Improvement Services

PO Box 361

Trenton, NJ 08625-0361

BLOOD CENTERS - 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 due date given on the attached cover letter. Please retain a copy of the report for your files. If assistance is needed, contact the Blood Bank Program of the Clinical Laboratory Improvement Service at 609-406-6829.
A.	SOURCES OF SUPPLY (Whole Blood and Packed Cells)	Totals
1.	Number of units on hand January 1
2.	Number of allogeneic units drawn by your bank (incl. all stations)
3.	Number of allogeneic units drawn by your bank in New Jersey
Number of double red cell procedures performed by your bank in New Jersey (allogeneic)

( __________ x 2 = __________. Add total to number 3. above.)	//////////////////////
5.	Number of autologous units drawn by your bank in New Jersey
6.	Number of directed units drawn by your bank in New Jersey
7.	Number of units received from Red Cross
8.	Number of units received from New York Blood Center
9.	Number of units received from N. J. Community Blood Banks
10.	Number of commercial units received from commercial sources.
11.	No. of commercial units received directly from volunteer Blood Banks.
12.	Number of volunteer units received directly through the American Association of Blood Banks
13.	Number of commercial units received directly through the American Association of Blood Banks.
14.	Number of volunteer units received from Out-of-State Community Blood Banks.
15.	Number of volunteer units received from Out-of-State Red Cross Centers other than Penn Jersey
TOTAL AVAILABLE SUPPLY
Name of Blood Bank

B. Distribution	Whole Blood	Packed Cells	Totals
Allogeneic	Autologous	Directed	Allogeneic	Autologous	Directed
1.	Number of units supplied to:
a.	New Jersey Hospitals
b.	Out-of-State Hospitals
c.	N. J. Community Blood Banks
d.	Regional Red Cross Centers
e.	American Association of Blood Banks
f.	Federal and Military Institutions
g.	Other (specify):
2.	On Hand December 31
C. Number of Units Discarded From:	Allogeneic	Autologous	Directed	Totals
Your Collections	Other Sources	Your Collections	Other Sources	Your Collections	Other Sources
1.	Outdating
2.	Reactive HBsAg
3.	Reactive HBcAb
4.	Reactive Test for HCV Antibody
5.	Reactive for Syphilis
6.	Reactive Test for HIV Antibody
7.	Reactive HTLV-I/II
8.	Elevated ALT
9.	Irregular Antibodies
10.	Contamination, Breakage, etc.
11.	Donor Deferral Registry or Confidential Unit Exclusion
12.	Other (Specify)

(e.g., equipment failure):

TOTAL DISCARDS
PERCENT DISCARDED
Name of Blood Bank

D.	NUMBER OF UNITS IN SECTION C. ABOVE, CONFIRMED POSITIVE FOR:
1.	HIV
2.	HBsAg
3.	HCV
4.	STS
E. BLOOD COMPONENTS	Number of Units
Prepared

In Your

Blood Bank	Obtained from Other Sources	Distributed to New Jersey Hospitals	Distributed to Out-of-State Hospitals
Name	Number
1.	Fresh frozen plasma
2.	Single Donor Platelets
3.	Platelet concentrates
4.	Cryoprecipitates
5.	Frozen red cells
6.	Washed red cells
7.	Prestorage leukoreduced RBC
8.	Leukocytes
9.	Other (Specify):
APHERESIS/

THERAPEUTIC PHLEBOTOMY	Number of	Total Discarded	Distributed to
Donors	Units
NJ Hospitals	Out-or-State

Hospitals
1.	Plasmapheresis
2.	Leukapheresis
3.	Plateletpheresis
4.	Stem Cells
5.	Therapeutic Phlebotomy
Name of Blood Bank

G.	SALVAGED PLASMA	Your

Collections	Hospitals	Out-of-State
1.	Number of Units Obtained From:
2.	Units Distributed to (Name)	Address	Amount (Liters)
a.
b.
c.
d.
e.
f.
TOTALS
H.	NUMBER AND TYPE OF DONOR REACTIONS	Slight	Moderate	Severe
Adverse Donor Reactions

(Specify type, e.g., convulsions, etc.): *

a.	Number of Donors Transported to the Emergency Room	/ / / / / / / / / / / / / /	/ / / / / / / / / / / / / /
* If you need additional space, please attach additional sheets.

Name of Blood Bank Director (Print)

Telephone Number

Signature of Blood Bank Director	Date

BLOOD CENTERS – ANNUAL STATISTICAL DATA

(Continued)

CL-51

JUL 12	Page 4 of 4 Pages.

JUL 12	Page 1 of 4 Pages.

CL-51, Blood Centers, Annual Statistical Data

CL-51, blood center, blood, annual report, statistical data, clinical lab improvement service, blood banks, CLIS

EWhite

2001-03-22

NJDOH