New User Registration



Thank you for registering. Please fill in the form below. You information will be reviewed and we will notify you as soon as your membership is approved.

User Name:
Prefix:   First Name:   
Last Name:
Organization:
Street Address:
City:
State (if applicable):
Post Code:   
Country:              
Phone:
Fax:
Email Address:
Password:
Repeat Password:
User Type:
What type is your organization: A blood collector
A hospital
Other:
How many units of blood does your organization collect every year?
We understand this may vary: please give your best approximate answer
Which "arm-to-arm" activities are you involved in?
Please tick all that apply

Donor
Collection
Processing
Testing
Inventory
Patient
Other:
If a blood collector, how do you collect blood from donors?
Please tick all that apply
Fixed site(s)
Mobile team(s)
Bloodmobile(s)
Approximately what proportion of your blood is tested for Transfusion Transmitted Infections
Please give a number, from 0(%) to 100(%)
%
Approximately what proportion of blood collected is transfused as WHOLE blood?
Please give a number, from 0(%) to 100(%)
%
What products - if any - do you collect through apheresis ("automation")
Please tick any/all that apply. Add text in "other" if explanation is required
Red cells
Platelets
Plasma

Other:
Do you engage in therapeutic apheresis?
Add text in "other" if explanation is required
Yes
No

Other:
In general, how would you describe the supply of electricity to your organization? Good
Sporadic
Poor
   

Authorization and References:

Please supply the contact details of a senior person within your organization, ideally the CEO or Medical Director. Finally, please tick to indicate that they are aware of and have approved this application. Thank you
 
Full name
Position (job title)
Address
Contact telephone number
Contact email address
The person whose details are given above has authorized this application Yes
No