Tissue Bank

Renewal Checklist

1. Form LAB 171​ (PDF) Renewal Application
2. Form LAB 169 (PDF) [All current personnel information] -OR- [if there are more than 10 Tissue Bank staff, report supervisor information only]
3. Form LAB 170 (PDF) Assisted Reproductive Technology (ART) Questionnaire, if applicable
4. Form LAB 184 (PDF, 1.4 MB) Contact Person sheet
5. Patient Consent form(if applicable)
6. Operations Affirmation Letter (PDF, 1.5 MB)
   
7. Renewal fee enclosed:
   • Refer to Fee Schedule webpage​​
     
   • No license fee required for a tissue bank operated by the State of California, California State agency, health care district, city, or county
   • Check made payable to “CDPH” or “Tissue Bank Fund”
   • Please write the Tissue Bank license number on check
   • You may print this webpage. This checklist serves as the Tissue Bank License renewal invoice

Tissue Banks located in California:

8. List of all tissue vendor from whom you have received or to whom you have sent tissue within the previous 12 months.
   (Include each vendor name, address, California Tissue Bank license number.)
9. Inventory totals of all allograft tissue types manufactured, purchased, stored, or used within the last 12 months - include, if applicable, totals of sperm, oocytes, or embryos.​
   

Tissue Banks located outside California:

10. Total number of each type of tissue received ​​ from California or sent to California.

11. Total number of each type of tissue stored that originated from California.​