Facility Annual Return Form

The Facility Annual Return Form must be completed by the main facility. For more information, please refer to the instructions below.

FACILITY ACTIVITY (include the activity from all sites, and provide one aggregate number)

Blood

Whole Blood units collected (excludes cord blood):
Apheresis donation procedures performed (excludes cellular therapy collections):
Blood product pools prepared:

Cellular Therapy (e.g., apheresis, marrow, cord blood, adipose)

Cellular Therapy collections:
Cellular Therapy products processed:

Tissue - Non Ocular*

Tissue products distributed that are labeled with ISBT 128**:

Tissue - Ocular*

Tissue products distributed that are labeled with ISBT 128**:
*Does your facility only store tissue (i.e., does not collect, recover, process)?
    

**For tissues collected with the intent of being processed into cellular therapy products, include figure in the “Cellular Therapy collections” field (above).


HCT/P Medical Devices

HCT/P Medical Devices:

Human Milk Banking

Liters distributed:

Plasma Fractionators

Units collected and labeled with ISBT 128:
Products distributed labeled with ISBT 128:

Reproductive Facilities

Units collected and labeled with ISBT 128:
Products distributed labeled with ISBT 128:

Organ Transplant

Final Products:

Fecal Microbiota

Final Products (treatments) Produced:

Regenerative Medicine

Final Products Produced:
FACILITY INFORMATION*
ISBT 128 Facility Identification Number:
*
Facility Type (check all that apply):
                          
*

*For US facilities registered and/or licensed with the FDA, the name and location of your facility should match what appears on your FDA registration or license.

Facility Name (EXACTLY as it should appear in our database):
*
Facility Address:
*
City:
*
State/Province:
*
Postal Code:
*
Country:
*
Is your facility address the same as your billing/mailing address?
    
*

If you selected 'Yes' for the previous field, you may skip down to the "CONTACT INFORMATION" field.

Billing/Mailing Address:
City:
State/Province:
Postal Code:
Country:

__________________________________

CONTACT INFORMATION
Primary Contact Name (including Job Title):
*
Primary Contact Email Address
*
Phone Number:
*
Fax Number:
Web Address:
Secondary Contact Name (including Job Title):
Secondary Contact Email Address:

__________________________________

OTHER INFORMATION
Other ISBT 128 Facility Identification Numbers (FINs) linked to this registration:
Would you like to receive email notifications regarding important information about ISBT 128?
    
*
Comments:

Facility Annual Return Instructions

Determine which form(s) you need to complete.

    1. If you are registered as a corporation that requested multiple FINs under a single registration, complete this form and an Associated Facility Annual Return Form for EACH facility that has an assigned FIN.

      For example, Large University Medical Center (FIN is W0001) has three associated facilities under a single ICCBBA registration: Large University Medical Center - Bedford (W0002), Large University Medical Center - Centerville (W0003) and Large University Medical Center - Springfield (W0004). This organization should complete the Facility Annual Return Form for Large University Medical Center (W0001) and an Associated Facility Annual Return Form for each of the three other hospitals (Bedford, Centerville and Springfield).

    2. In the Activity Box, enter aggregate numbers for all facilities associated with this registration (if applicable).

      For example, using the facilities described above, Large University Medical Center collects 23,000 units of whole blood each year. Bedford collects 6,000; Centerville 4,000; and Springfield 2,000. For Whole Blood Units Collected, enter the total for the 4 hospitals (35,000).

    3. For Human Development Index (HDI), enter if your facility is in a Medium or Low HDI country. You can view a list of countries around the world and their corresponding HDI here.

For all additional Facility Identification Numbers (FINs) associated with this registration, complete an Associated Facility Annual Return Form.

 

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