Healthcare Blood Donation Form

HEALTHCARE BLOOD DONATION FORM

The information requested on this form is required to determine eligibility to donate whole blood or blood components. All answers must be complete and accurate. The donor certifies that the information provided is true to the best of their knowledge and understands that knowingly providing false information may put recipients at risk.

Donor Information

Date of birth:    Gender: Male   Female   Other / Prefer not to say

Emergency Contact

Insurance Information (if applicable)

Medical History & Screening Questions

Please answer the following questions. For each item, check Yes if it applies to you or No if it does not.

1. Are you feeling well today (no fever, flu-like symptoms)? Yes No

2. Have you had a cold, sore throat, fever, or flu in the last 7 days? Yes No

3. Have you received a vaccination within the last 48 hours? Yes No

4. Have you donated blood in the last 56 days? Yes No

5. Have you ever tested positive for or been treated for hepatitis, HIV/AIDS, or syphilis? Yes No

6. Have you used needles to inject non-prescribed drugs at any time? Yes No

7. In the past 3 months, have you traveled to or spent extended time in areas with risk for malaria or other transfusion-transmissible infections? Yes No

8. For female donors: Are you pregnant or currently breastfeeding? Yes No

9. Have you ever had a reaction to donating blood (fainting, seizure, hematoma)? Yes No

Current Health / Medications

Pre-Donation Measurements (to be completed by staff)

Weight (lb):    Blood pressure (systolic/diastolic):    Pulse (bpm):

Hemoglobin / Hct (if measured):

Consent, Testing, and Authorization

I understand that the blood I donate will be tested for infectious agents and other markers as required by applicable standards. If a test result indicates infection or other conditions that may affect the safety of blood products, I authorize the blood collection facility to notify public health authorities and to attempt to notify me. I understand I will be notified if results require medical follow-up.

I consent to the collection of blood and authorize the use of my personal health information as necessary for donor screening, testing, processing, storage, and distribution of blood products. I authorize release of test results and relevant health information to treating medical personnel or public health officials when required by law.

I understand the known risks of donation, which include fainting, bruising, hematoma, nerve irritation or injury, infection at the needle site, and in rare cases more serious complications. I consent to receive appropriate first aid or medical treatment for adverse events that occur during or immediately after donation.

I authorize that residual samples from my donation may be retained, de-identified, and used for quality control, validation testing, or research consistent with applicable law. I understand I have the right to withdraw consent prior to donation; withdrawal after donation will not prevent testing or use of material already collected in accordance with regulatory and safety requirements.

Privacy & Acknowledgment

I acknowledge that I have been offered the facility's privacy notice describing how my health information will be used and disclosed in connection with this donation. I understand that blood center personnel may access my medical records or contact my healthcare provider if necessary for donor safety.

I certify that the answers I have given on this form are complete and true. I understand that providing false answers or withholding information may endanger recipients of blood products and may be unlawful.

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