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VITY REPORT Directions for completion of form Complete and return no later than 10 calendar days following the end of a calendar month. Clinical Laboratory Program 99 Chauncy Street, 2nd Floor Boston, MA 02111 Phone 617-753-8439 Fax 617-753-8240 Page 1 Blood Bank Demographics Complete all information: Facility number (page 1 and 2), Name, Address, Bed Size Names of Blood Bank Medical Director and Supervisor Blood Bank phone number (include area code) Adverse Effects of Transfusions DISEASE TRANS.

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