SUPPLEMENTAL APPLICATION
BLOOD / DONOR BANKS
MISCELLANEOUS HEALTHCARE FACILITIES
This application must be completed, signed and dated by the applicant. All questions must be answered completely. The
information is required to make an underwriting and pricing evaluation. Your answers are considered legally material to that
evaluation. If any question does not apply, indicate NOT APPLICABLE. If space is not sufficient to properly answer the
question, please provide the details in the Additional Information section of this form or you may attach a separate page using
your letterhead. To use this form, you may mouse click on a field or move between fields using the tab key. To check a box,
you may mouse click or press the space bar.
I. GENERAL INFORMATION
1
Applicant Name:
II. EDUCATION AND TRAINING
1
Type and Number of Annual Exposures: (check all that apply)
Projected Year
Annual Donations
Current Year
Prior Year
Paid Blood Donations
Volunteer Blood Donations
Autologous Blood Donations
Foreign (not USA) Donations Purchased
Pheresis
Outpatient Transfusions
Therapeutic Plasma Exchange
Stem Cell Harvesting
Other
Projected Year
Annual Receipts
Current
Year
Prior Year
Organ Banking – Direct Processing
Organ Banking – No Direct Processing
Tissue Banking
Sperm Banking
Egg Banking
2
3
4
5
Other:
Is there any research activity?
If yes, please describe:
Do you provide testing for other donor facilities?
If yes:
Type of Test
Yes
No
Yes
No
Estimated Annual Number of Each
Do you require the other facility to carry professional liability limits equal to your limits?
Yes
No
Does another facility test blood for you?
If yes, please complete the following:
Yes
No
Name of Facility
Type of Test
Estimated Annual Number of Each
Do you require the other facility to carry professional liability limits equal to your limits?
Do you check with the Donor Registry before the donor’s blood is taken or transfused?
MHF 08 0006 01 13
© 2013 General Star, Stamford, CT
Yes
Yes
No
No
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Have you implemented the FDA recommendations for questions related to potential donors regarding the following:
a HIV Testing?
Yes
No
b Hepatitis Testing?
Yes
No
c Smallpox?
Yes
No
d Anthrax?
Yes
No
e Other infectious diseases?
Yes
No
ADDITIONAL INFORMATION
Please use the space provided below to provide additional information as required by individual questions in this application.
Use additional sheet(s) if necessary.
Section # and
Question #
Comments
Signature:
MHF 08 0006 01 13
Date:
© 2013 General Star, Stamford, CT
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