Form LAB171 "Tissue Bank License - Renewal Application" - California

What Is Form LAB171?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2007;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form LAB171 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form LAB171 "Tissue Bank License - Renewal Application" - California

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State of California—Health and Human Services Agency
California Dept. of Public Health
Laboratory Field Services
850 Marina Bay Parkway
Bldg. P, 1st Floor
Richmond, CA 94804-6403
TISSUE BANK LICENSE - RENEWAL APPLICATION
Division 2, Chapter 4.1, California Health and Safety Code
Our records show that the provisional tissue bank license for:
ID number:
Name:
Address:
City, state, and ZIP code:
Expires on:
INSTRUCTIONS
To renew the provisional tissue bank license, complete this form and the Tissue Bank Personnel Report (LAB 169). Return
both with the current fee. (No fee is required of district, city, county, or state facilities.) Make check payable to: State of
California Tissue Bank Fund.
California Department of Public Health
SEND TO:
Laboratory Field Services
850 Marina Bay Parkway, Bldg. P, 1st Floor
Richmond, CA 94804-6403
Yes No
1. Has there been a change in the name, ownership, director(s), and/or location of this tissue bank? If yes,
state changes on the reverse of this form. ................................................................................................................ ❒
2. Has there been a change in the type of tissue(s) collected, processed, stored, or distributed by the tissue bank?
If yes, state changes on the reverse of this form. ..................................................................................................... ❒
3. Has there been a change in any of the processes utilized by the tissue bank (1) to ensure safe preservation,
transportation, storage, and handling of tissue acquired or used by the tissue bank, (2) to determine if donors
have been tested or assessed for the transmission of disease through transplantation, or (3) to determine, when
appropriate, if donors have been tested to determine compatibility? If yes, state changes on the reverse of this
form or on a separate page. ...................................................................................................................................... ❒
USE REVERSE SIDE FOR CHANGES
NOTE: Chapter 4.1, Section 1639.3(c) of the California Health and Safety Code, states in part, “Failure to pay the additional
annual fee shall result by operations of law, in automatic expiration of the provisional license one year from the date of its
original issuance. If the provisional license does so expire, the applicant may not continue to operate a tissue bank pending
the department’s determination of whether a license shall be granted or denied.”
This statement to be signed by owner or person legally authorized to bind the owner.
I declare under penalty of perjury that the foregoing statements are true and correct.
Signature
Title
Signed this day of ___________________________, in _______________________________, ______________________.
(city)
(state)
LAB 171 (7/07)
State of California—Health and Human Services Agency
California Dept. of Public Health
Laboratory Field Services
850 Marina Bay Parkway
Bldg. P, 1st Floor
Richmond, CA 94804-6403
TISSUE BANK LICENSE - RENEWAL APPLICATION
Division 2, Chapter 4.1, California Health and Safety Code
Our records show that the provisional tissue bank license for:
ID number:
Name:
Address:
City, state, and ZIP code:
Expires on:
INSTRUCTIONS
To renew the provisional tissue bank license, complete this form and the Tissue Bank Personnel Report (LAB 169). Return
both with the current fee. (No fee is required of district, city, county, or state facilities.) Make check payable to: State of
California Tissue Bank Fund.
California Department of Public Health
SEND TO:
Laboratory Field Services
850 Marina Bay Parkway, Bldg. P, 1st Floor
Richmond, CA 94804-6403
Yes No
1. Has there been a change in the name, ownership, director(s), and/or location of this tissue bank? If yes,
state changes on the reverse of this form. ................................................................................................................ ❒
2. Has there been a change in the type of tissue(s) collected, processed, stored, or distributed by the tissue bank?
If yes, state changes on the reverse of this form. ..................................................................................................... ❒
3. Has there been a change in any of the processes utilized by the tissue bank (1) to ensure safe preservation,
transportation, storage, and handling of tissue acquired or used by the tissue bank, (2) to determine if donors
have been tested or assessed for the transmission of disease through transplantation, or (3) to determine, when
appropriate, if donors have been tested to determine compatibility? If yes, state changes on the reverse of this
form or on a separate page. ...................................................................................................................................... ❒
USE REVERSE SIDE FOR CHANGES
NOTE: Chapter 4.1, Section 1639.3(c) of the California Health and Safety Code, states in part, “Failure to pay the additional
annual fee shall result by operations of law, in automatic expiration of the provisional license one year from the date of its
original issuance. If the provisional license does so expire, the applicant may not continue to operate a tissue bank pending
the department’s determination of whether a license shall be granted or denied.”
This statement to be signed by owner or person legally authorized to bind the owner.
I declare under penalty of perjury that the foregoing statements are true and correct.
Signature
Title
Signed this day of ___________________________, in _______________________________, ______________________.
(city)
(state)
LAB 171 (7/07)
COMPLETE THIS SIDE ONLY IF CHANGE HAS OCCURRED
Effective date of change: __________________
1.
Name of tissue bank
Telephone number
(
)
Address (number, street)
City
ZIP code
Check type of ownership
❒ Individual—If an individual owns the tissue bank, give name and address of the individual.
❒ Partnership or unincorporated association—If partnership or unincorporated association (whether general or limited),
give names of all the members of the partnership or association.
❒ Corporation—If a corporation owns the tissue bank, state the name of the officers, directors, shareholders holding a
five percent or more interest in the corporation, and any person, partnership, or corporation who or which has the
responsibility to manage or conduct the day-to-day operation of the tissue bank. (Use supplementary sheet if
necessary.)
Exact Name of Owner
Address—(Location where any fictitious permit is filed)
Hours per week
to be spent in
Name(s) of Director(s) of Tissue Bank
Address
this facility
2. List type of tissue(s) collected, processed, stored, or distributed by the tissue bank.
Living Donors
Deceased Donors
3. Describe or attach description of any process utilized by the tissue bank (1) to ensure safe preservation, transportation,
storage, and handling of tissue acquired or used by the tissue bank, (2) to determine if donors have been tested or
assessed for the transmission of disease through transplantation, or (3) to determine when appropriate, if donors have been
tested to determine compatibility.
LAB 171 (7/07)
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