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Establishment Information Tissue Establishment Name Licence Number

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					Establishment Information
Tissue Establishment Name
Licence Number
Address
Postcode
Does your establishment have MHRA accreditation?

Declaration
To the best of my knowledge and belief the information in this is Annual Report is correct and complete
DI Name
Date
Other Name
Date
Position
Please indicate which of the licensable activities are carried out at the establishment or
by an unlicensed third party on your behalf under a third party agreement.
Please familiarise yourself with the definitions of the different licensable activities in the
Human Application sector and only report those that are carried out at the establishment.


Activities Undertaken in 2010
Procurement (of tissues or cells)
Testing (of tissues or cells)
Processing (of tissues or cells)
Storage (of tissues or cells)
Distribution (of tissues or cells)
Import/Export (of tissues or cells)

This year the Annual Activity Data collection exercise will also be used to gather
information required to calculate the licence fees for the Human Application sector.
Please email licensing.enquiries@hta.gov.uk if these activities will be changing in 2011
and the HTA will contact you about the changes.


Types of tissues and/or cells
Select 'Yes' for types of tissues or cells that are relevant to your HTA licence, for other
please specify.
Please note a maximum of 9999 units will be stored. If you have further units please
email licensing.enquiries@hta.gov.uk

Skeletal Tissues
Bone
Tendons/Ligaments
Cartilage

Other Skeletal Tissues
Demineralised Bone
Acellular Bone Chips

Haematopoetic Stem Cells(HSC)
Bone Marrow
Peripheral Blood Stem Cells
Donor Lymphocyte Infusion
Other HSC

Umbilical Cord Blood
Umbilical Cord Blood

Ocular Tissues
Cornea
Sclera
Ocular Limbal Stem Cells
Other Ocular Tissues

Cardiovasclular Tissues
Heart Values
Arterial Values
Other Cardiovascular Tissues

Skin
Skin

Tissues or Cells procured for ATMPs or IMPs
Tissues or Cells procured for ATMPs or IMPs

Other Tissues or Cells
Pancreatic Islets
Hepatocytes
Amniotic Membrane
Other (general)
Third Party Agreements

Please indicate which UNLICENSED establishments carry out the following activities on your behalf under a Third Party Agreement (TPA).
Please refer to the guidance document for a definition of these activities.

If you have a large number of TPAs you can send a seperate excel spreadsheet to licensing.enquiries@hta.gov.uk

Name                               Address                           Contact            Procurement Testing       Processing Distribution Import/Export
Skeletal Tissues

                                                                                                        Tendons and   Demineralised   Acellular
                                                                     Bone Bone Grams Cartilage Meniscus Ligaments     Bone            Bone Chips
                                                                     Units Units     Units     Units    Units         Units           Units
How   many units procured?
How   many units tested?
How   many units processed?
How   many units stored?
How   many units released for treatment?
How   many units accepted into the TE?
How   many units distributed from the TE?
How   many units imported?
How   many units exported?
How   many units disposed of?
How   many units were not fully traceable from donor to recipient?
Haematopoetic Stem Cells
                                                                   Bone Marrow   Peripheral Blood Stem Cells   Donor Lymphocyte Infusions
                                                                   Units         Units                         Units
How many units procured?
How many units tested?
How many units processed?
How many units stored?
How many units released for treatment?
How many units accepted into the TE?
How many units distributed from the TE?
How many units imported?
How many units exported?
How many units disposed of?
How many units were not fully traceable from donor to recipient?

Haematopoietic Stem Cell Transplantation
                                                                   Bone Marrow   Peripheral Blood Stem Cells
How many autologous donations?
How many related donations?
How many unreleated donations?
How many autologous transplants?
How many related transplants?
How many unrelated transplants?
Cord Blood
                                                                   Umbilical Cord Blood
                                                                   Units
How many units procured?
How many units tested?
How many units processed?
How many units stored?
How many units released for treatment?
How many units accepted into the TE?
How many units distributed from the TE?
How many units imported?
How many units exported?
How many units disposed of?
How many units were not fully traceable from donor to recipient?

Haematopoietic Stem Cell Transplantation
                                                                   Haematopoietic Stem Cell Transplantation
How many autologous donations?
How many related donations?
How many unreleated donations?
How many autologous transplants?
How many related transplants?
How many unrelated transplants?
Ocular Tissues
                                                                   Cornea   Ocular Limbal Stem Cells   Sclera
                                                                   Units    Units                      Units
How many units procured?
How many units tested?
How many units processed?
How many units stored?
How many units released for treatment?
How many units accepted into the TE?
How many units distributed from the TE?
How many units imported?
How many units exported?
How many units disposed of?
How many units were not fully traceable from donor to recipient?
Cardiovascular Tissues
                                                                   Heart Valves   Arterial Vessels
                                                                   Units          Units
How many units procured?
How many units tested?
How many units processed?
How many units stored?
How many units released for treatment?
How many units accepted into the TE?
How many units distributed from the TE?
How many units imported?
How many units exported?
How many units disposed of?
How many units were not fully traceable from donor to recipient?
Skin
                                                                   Skin    Skin Cm2
                                                                   Units   Units
How many units procured?
How many units tested?
How many units processed?
How many units stored?
How many units released for treatment?
How many units accepted into the TE?
How many units distributed from the TE?
How many units imported?
How many units exported?
How many units disposed of?
How many units were not fully traceable from donor to recipient?
Procured for ATMPs or IMPs

                                                                   Units
How many units procured?
How many units tested?
How many units processed?
How many units stored?
How many units released for treatment?
How many units accepted into the TE?
How many units distributed from the TE?
How many units imported?
How many units exported?
How many units disposed of?
How many units were not fully traceable from donor to recipient?
Other Tissues or Cells
                                                                   Amniotic Membrane   Hepatocytes   Pancreatic Islets
                                                                   Units               Units         Units
How many units procured?
How many units tested?
How many units processed?
How many units stored?
How many units released for treatment?
How many units accepted into the TE?
How many units distributed from the TE?
How many units imported?
How many units exported?
How many units disposed of?
How many units were not fully traceable from donor to recipient?

				
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