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FORM B

Private umbilical cord blood collection: to be signed and returned to the Trust by the private bank

Name of patient: / ______
Address: / ______
______
Hospital number: / ______

The Homerton University Hospital NHS Foundation Trust (“the Trust”) has been notified that the above named patient has engaged your organisation to collect umbilical cord blood for the purposes of stem cell storage. The Trust is not licensed by the Human Tissue Authority (“HTA”) to undertake the collection or storage of stem cells from umbilical cord blood for private purposes.

The Trust requires that you comply with and agree to the following in order for you to attend our premises for the purposes of cord blood stem cell collection:

1  You must provide the Trust will the following as soon as possible and by week 36 at the latest:

1.1  confirmation that you have been engaged to arrange cord blood collection in respect of the above patient;

1.2  a copy of your Human Tissue Authority (HTA) licence;

1.3  confirmation of the independent stem cell phlebotomist(s) ("collector") that are likely to attend the Trust for the purposes of cord blood stem cell collection together with confirmation that they are a registered healthcare professional trained in cord blood collection and that they are duly authorised to collect cord blood on your behalf (e.g that they are employed by you or otherwise have a duly signed Third Party Agreement in place);

1.4  confirmation of your insurance arrangements and professional indemnity cover in respect of the relevant collector(s);

1.5  confirmation that an appropriate CRB check has been carried out in respect of the relevant collector(s) and details of any information that has been revealed as a result of such check.

2  By signing this Form B, you acknowledge and agree:

2.1  that the Trust will not become involved in the umbilical cord blood collection and that the Trust and its staff will have no involvement in or responsibility for the cord blood collection procedure;

2.2  that the collection of umbilical cord blood should not impact adversely on the quality of midwifery/medical care or the immediate care of the mother and baby. In particular, the management of the third stage of delivery will not be altered or delayed to promote successful cord blood collection;

2.3  in the event of a medical emergency such as post partum haemorrhage, medical treatment shall take priority over commercial umbilical cord blood collection;

2.4  that the collection of cord blood for Rhesus factor or any other medical reason which will be performed by midwifery/obstetric staff shall take precedence over commercial umbilical cord blood collection.

3  Your collector must display appropriate ID at all times whilst on the Trust's premises. If the collector does not have the ID available, he may be denied access to the Trust and/or the delivery suite/ward/theatre.

4  Your collector with liaise with the Midwife/Obstetrician and patient/birth partner in relation to the optimum opportunity for stem cell blood collection to take place. It is anticipated that the collection of cord blood by your collector will take place within the delivery suite/ward/theatre but outside of the delivery room.

5  Your collector must vacate the delivery room or delivery suite/ward/theatre (as appropriate) if asked to do so by a member of the Trust’s staff.

6  It is your collector’s responsibility to obtain consent for the procedure.

7  Your collector must adhere to the Trust’s policies for the prevention of needle stick injuries and infection control and any other policies or procedures (including, for the avoidance of doubt, any health and safety policies) duly notified by the Trust to the collector.

8  The sole responsibility for the sample of cord blood which your collector obtains remains with you at all times.

9  All equipment required for the commercial umbilical cord blood collection must be provided by you. Your collector is responsible for the safe disposal and removal of sharps and syringes.

10  At all times, the Trust expects your collector to behave professionally, discreetly and courteously.

1  You agree that the Trust has no liability for any direct or indirect losses, costs or expenses howsoever caused in connection with the collection of the cord blood.

Please complete the details below to confirm you have read, understood and agree to the above on behalf of your company and return the duly completed form with the information requested in paragraph 1 above to the Head of Midwifery at Homerton University hospital, Homerton Row, London, E9 6SR.

Name
Signature
Date / ______