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Donor questionnaire
Thank you for coming to give blood today. Your donation could save the life of someone or help them through an operation (surgical procedure). The Australian Red Cross Blood Service is committed to providing safe blood and blood products to those who need them.
The Donation Process
On the Day
We are going to ask you to answer some questions about your general • Eat up. Make sure that you eat something in the 3 hours before health to help us to decide if it is safe for you to give blood and, if so, how we can best use your blood. All of these questions are important though • Be prepared by having plenty of liquid the day before donation, the reasons for some of the questions may be difficult to understand. especially in warm weather. In addition, in the 3 hours before Please discuss them with the member of staff who will be interviewing donating, please drink at least 3 good-sized glasses of water/juice.
you. We are committed to keeping your answers and anything you tell us in the interview CONFIDENTIAL in so far as we are able.
• Provide identification: Have your photo ID or donor ID card handy.
Even though there are a lot of questions, you need to answer them You should fill in the declaration section but please don’t sign until you
honestly and to the best of your ability. Answering these questions honestly have completed the interview!
is important to ensure the safety of blood products. There are severe penalties, including fines and/or imprisonment, for false or misleading information.
Blood is tested primarily to ensure recipient safety. Donors should never
rely on this testing for their own personal health screening purposes.
Prior to release, all donations must be tested for the presence of hepatitis
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B, hepatitis C, HIV (AIDS virus), HTLV and syphilis. Should your blood For your records
test positive or show a significantly abnormal result, you will be notified. However, on some occasions laboratory testing cannot be performed and SAMPLE ONL
A staff member will enter your details below:
You have the option to change your mind about donating blood at any time. Please indicate to staff if you wish to leave at any time during the donation process.
D D / M M / Y Y Y Y
Complete using ink – not pencil. If you make a mistake, cross it out and initial the correction. Do not use liquid paper as this will invalidate the The Blood Service acceptable ranges for haemoglobin are: form and you will need to complete a new form.
Whole blood donors:
Privacy statement
Females 120 to 165 g/L and Males 130 to 185 g/L The personal information collected on this form allows the Blood Service to register and retain you as a blood donor. All information collected will Plasma and platelet donors:
be handled in the strictest confidence in accordance with the Privacy Act Females 115 to 165 g/L and Males 125 to 185 g/L For more information, please ask for a Privacy brochure.
call 13 14 95 or visit donateblood.com.auStock No. 15340947ARCBS-DAP-L3-026 | Version: 10 | Date Effective: 1 July 2012 | Page 1 of 6 i Information about the risks of donating blood
Blood donation is extremely safe
However, problems occasionally arise during or after a donation. These problems are not common but we are telling you
about them so that, if they do occur, you will know some simple and appropriate steps to take.
Please note: Al equipment used in blood collection is sterile, used once only and discarded.
If you experience any problems or you feel unwell whilst you are at the donor centre sit down and ask a staff member
for assistance. Are you feeling anxious? Please let us know. We can help you feel at ease.
Feeling faint and fainting
• Avoid lifting or carrying anything with your donation arm for 30 minutes and minimise heavy lifting for 24 hours.
Fainting is caused by a reflex which slows your pulse and lowers your blood • Keep the bandage on your arm for 2 hours.
If you develop a bruise that causes discomfort, an icepack and/or a mild About 1.5% of blood donors may feel faint (dizzy, light headed, hot, sweaty or pain reliever such as paracetamol (not aspirin or other anti-inflammatory unwell) during or immediately after their donation. A much smaller number of medication e.g. ibuprofen), may help. Do not put ice or ice packs directly onto donors (about 0.15%) faint (lose consciousness).
your skin – always wrap the ice/ice pack and only use it for up to 20 minutes About 0.15% of donors will feel faint or faint after they have left the donor If you start bleeding from the needle site, you should apply pressure to the Reducing the chance of fainting
bleeding site and lift your arm above your shoulder for 15 minutes while • You should drink 3 good-sized glasses of water/juice prior to visiting the Blood Donor Centre. Be prepared by having plenty of liquid in the Please phone the Blood Service on 13 14 95 if bleeding or bruising occurs so 24 hours before donation, especially in warm weather.
• Make sure that you eat something in the 3 hours before donating – Uncommon events
• If you usually have low blood pressure and feel faint when you stand up • Nerve irritation - sometimes the donation needle may irritate a nerve suddenly, please tell us prior to donating.
under the skin. This may cause pain which is normally only momentary. • Tense and relax your calf and thigh muscles repeatedly and move your If any pain persists following the insertion of the needle please advise staff immediately. Pressure on a nerve may also cause temporary • Spend at least 15 to 20 minutes in the refreshment area and have a cool drink after donating to allow your blood volume to adjust.
• Needle inserted into an artery – once identified the needle will be To reduce your chance of fainting after you have left the Blood Donor Centre, • Infection or thrombosis – if you develop redness, tenderness or swelling this may be due to infection and/or a blockage of the vein with a blood • Continue to drink plenty of cool fluids but avoid alcoholic and hot drinks.
• Avoid standing still for long periods, do not rush or do strenuous exercise • Increase in pulse rate or a sensation of tightness or pain in the chest.
If you have any of these symptoms or concerns whilst in the Blood Donor What to do if you feel faint
Centre please let the staff know immediately so they can assist. If symptoms If you feel faint or unwell whilst you are at the Blood Donor Centre please tell a develop after leaving the Blood Donor Centre, and you require urgent attention, first seek attention from a hospital or doctor so the problem can be assessed. If you are unsure whether you should seek medical attention, please call us for If you feel faint after you have left the donor couch, immediately sit or lie down SAMPLE ONL
advice and if you do see a doctor we would like to hear the outcome - please as flat as possible to avoid falling and injuring yourself and: • Remain lying down for around 30 minutes or until you feel well again.
• Whilst lying down , tense your calf and thigh muscles for 5 seconds, then Iron levels and blood donation
relax, and repeat this every 1 - 2 minutes.
Red blood cells are rich in iron and therefore blood donation results in iron • Sit up for at least 4-5 minutes before you stand up.
loss. If your iron stores fall too low, you may become iron deficient. This may • Drink plenty of cool fluids (at least 2 good sized glasses) and have a • Tiredness and/or difficulty concentrating.
• Do not drive for at least 6 hours after you have recovered because there • Low haemoglobin levels (anaemia).
is a small risk that you may faint again whilst you are driving Before donating, all donors undergo a haemoglobin screening test. This is If you feel faint whilst you are driving, slow down and stop the car as soon as to ensure we do not take blood from donors who have or may be at risk of it is safe to do so. Remain in the car, and lay your seat as flat as possible. It is anaemia. If your haemoglobin is below our guidelines we will delay your recommended that you do not get out of your car as fainting beside a road can donation and may refer you to your general practitioner. be hazardous. Do not attempt to drive again. Call 000 for an ambulance.
The haemoglobin screening test is not a direct measure of iron levels and therefore Bruising and bleeding
does not detect all cases of iron deficiency. To help replace the iron loss associated Small bruises at the needle site are not unusual, but generally cause very few with donation, and prevent iron deficiency and anaemia, we recommend you have problems and disappear fully within a week. Larger bruises or bleeding from a healthy dietary intake of iron rich foods. This may not be sufficient for all donors, especially youth donors and women of childbearing age. If you have concerns about To reduce the risk of bruising and bleeding at the needle site your iron levels or would like further information, please discuss with a member of staff and/or your general practitioner. More information can be obtained in our • Avoid using your donation arm to eat and drink while at the Blood Donor brochure “Why iron and haemoglobin are important”. Centre and be careful when putting on a jacket after donating.
ARCBS-DAP-L3-026 | Version: 10 | Date Effective: 1 July 2012 | Page 2 of 6 A New and returned donors
Please complete this section only if:
• you are a new donor, or
• you have not donated within the last 2 years.
Otherwise, proceed to section B.
Please respond by placing a cross or a tick in the relevant box. Do not circle.
Have you:
Comments (staff use only)
1. Ever volunteered to donate blood before? 3. Ever suffered from anaemia or any blood disorder? 4. Ever had a serious illness, operation or been admitted to hospital? 5. Had a neurosurgical procedure involving the head, brain or spinal cord between 6. Ever received a transplant or graft (organ, bone marrow, cornea, dura mater, bone, etc.)? 7. Received injections of human growth hormone for short stature or human pituitary 8. Ever suffered from a head injury, stroke or epilepsy? 9. Ever had a heart or blood pressure problem, chest pain, rheumatic fever or 10. Ever had a bowel disease, stomach or duodenal problems or ulcers? SAMPLE ONL
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11. Ever had kidney, liver or lung problems including tuberculosis (TB)? 12. Ever had diabetes, a thyroid disorder or an autoimmune disease e.g. rheumatoid 13. Ever had cancer of any kind including melanoma? 14. Ever had malaria, Ross River fever, Q fever, leptospirosis or Chagas’ disease? 15. Ever had jaundice (yellow eyes/skin) or hepatitis? 16. Been outside Australia in the last 3 years? 18. From 1 January 1980 through to 31 December 1996 inclusive, have you spent (visited or lived) a total time which adds up to 6 months or more in England, Scotland, Wales, Northern Ireland, the Channel Islands, the Isle of Man, or the Falkland Islands? 19. Have you ever had treatment with the medication TIGASON (Etretinate) or ARCBS-DAP-L3-026 | Version: 10 | Date Effective: 1 July 2012 | Page 3 of 6 B Medical questionnaire
All donors please complete this section
Please respond by placing a cross or a tick in the relevant box. Do not circle.
Comments
2. Have you ever been pregnant (including miscarriage and termination of pregnancy)?
2a. If your answer is “Yes”– how many pregnancies? – have you been pregnant in the last 9 months? For safety reasons:
3. In the next 3 days, do you intend to participate in any activity which would place you or others at risk of injury if you were to become unwell after donating, such as: Driving public transport, operating heavy machinery, underwater diving, piloting In the last week, have you:
Y 4. Had dental work, cleaning, fillings or extractions?
5. Taken any aspirin, pain killers or anti-inflammatory preparations? 6. Had any cuts, abrasions, sores or rashes? 7. Had a gastric upset, diarrhoea, abdominal pain or vomiting? Since your last donation, have you – or if you are a new donor, have you in the last 12 months:
8. Been unwell, or seen a doctor or any other health care practitioner, had an operation (surgical procedure) or any tests/investigation? 9. Had chest pain/angina or an irregular heartbeat? SAMPLE ONL
10. Taken tablets for acne or a skin condition? 11. Taken any other medication, including regular or clinical trial medication? SAMPLE ONL
13. Had a sexually transmitted infection e.g. gonorrhoea, syphilis or genital herpes? 14. Had any immunisations/vaccinations including as part of a clinical trial? 16. Do you know of anyone in your family who had or has: • Gerstmann-Straussler-Scheinker syndrome (GSS)? Travel history and overseas residence:
17. Have you ever been outside Australia (including being born outside Australia)?
If your answer to question 17 is ‘No’ (i.e. you have never been outside Australia)– go straight to Section C
18. Have you ever spent a continuous period of 6 months or more outside Australia?
19. Have you ever received a transfusion or injection of blood or blood products outside Australia? Yes 20. Since your last donation have you been outside Australia? ARCBS-DAP-L3-026 | Version: 10 | Date Effective: 1 July 2012 | Page 4 of 6 C Donor declaration
All donors please complete this section
There are some people who MUST NOT give blood as it may transmit infections to those who receive it. To determine if your blood or blood
products will be safe to be given to people in need, we would like you to answer some questions. These questions are a vital part of our
efforts to eliminate diseases from the blood supply. All of the questions are important to answer. Answer each question on the form as honestly
as you can and to the best of your knowledge. THERE ARE PENALTIES INCLUDING FINES AND IMPRISONMENT FOR ANYONE PROVIDING FALSE OR
MISLEADING INFORMATION.
All donations of blood are tested for the presence of hepatitis B and C, HIV (the AIDS virus), HTLV and syphilis. If your blood test proves positive for any
of these conditions, or for any reason the test shows a significantly abnormal result, you will be informed.
Please respond by placing a cross or a tick in the relevant box. Do not circle.
To the best of your knowledge, have you EVER:
Comments (staff use only)
1. Thought you could be infected with HIV or have AIDS? 2. “Used drugs” by injection or been injected, even once, with drugs not
3. Had treatment with clotting factors such as Factor VIII or Factor IX? 4. Had a test which showed you had hepatitis B, hepatitis C, HIV or HTLV? In the last 12 months have you:
5. Had an illness with swollen glands and a rash, with or without a fever? 6. Engaged in sexual activity with someone you might think would answer “yes” to any of questions (1-5)? 7. Had sexual activity with a new partner who currently lives or 8. Had sex (with or without a condom) with a man who you think may have had oral 9. Had male to male sex (that is, oral or anal sex) with or without a condom? SAMPLE ONL
10. Been a male or female sex worker (e.g. received payment for sex in money, gifts or drugs)? 11. Engaged in sexual activity with a male or female sex worker? 12. Been imprisoned in a prison or been held in a lock-up or detention centre? 14. Had (yellow) jaundice or hepatitis or been in contact with someone who has? In the last 6 months have you:
15. Been injured with a used needle (needlestick)? 16. Had a blood/body fluid splash to eyes, mouth, nose or to broken skin? 17. Had a tattoo (including cosmetic tattooing), body and/or ear piercing, electrolysis or acupuncture (including dry-needling)? ARCBS-DAP-L3-026 | Version: 10 | Date Effective: 1 July 2012 | Page 5 of 6 C Donor declaration continued
This declaration is to be signed in the presence of a Blood Service
staff member (Please read the following conditions)
Thank you for answering these questions. If you are uncertain about any of your answers, please discuss them with your interviewer.
We would like you to sign this declaration in the presence of your interviewer (a Blood Service staff member) to show that you have understood the
information on this form and have answered the questions in the declaration to the best of your knowledge.
Your donation is a gift to the Blood Service to be used to treat patients. In some circumstances, your donation may be used by the Blood Service or other
organisations for the purposes of research, teaching, quality assurance or the making of essential diagnostic reagents (including commercial reagents).
A part of your donation will also be stored in our Blood Sample Archive for possible future testing and research; samples that are no longer required will be
destroyed. Approval from an appropriate Human Research Ethics Committee is required before any research is undertaken on your donation or any part of it.
You may be asked by the Blood Service to undergo further testing which you have the option to decline.
Should you become aware of any reason why your blood should not be used for transfusion after your donation, please call us on 13 14 95. In particular, if
you develop a cough, cold, diarrhoea or other infection within a week after donating, please report it immediately.
Acknowledgement of responsibilities and risks (Please initial and sign only in the presence of the interviewer)
I agree to have blood taken from me under the conditions above and:
• I have been provided with “Information about the risk of donating blood” on page 2 of this questionnaire. I have read and understood this information
and have had the opportunity to ask questions. I accept the risks associated with donation and agree to follow the instructions of the Blood Service staff to minimise these risks. • I declare that I have understood the information on this form and answered the questions in the declaration honestly and to the best of my knowledge. I understand that there are penalties, including fines and imprisonment, for providing false or misleading information.
Donor (please print)
D D / M M / Y Y Y Y
Please ONLY sign in the presence of the interviewer
Signature . Date D D / M M / Y Y Y Y
Staff witness (please print)
Donor identity verified
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Signature . Time . Date D D / M M / Y Y Y Y
Office use only: Record here any additional information if required for data entry, including malaria information.
Malaria Resident – Status Malaria resident permanent status I130 (identify previous malaria residency)
Malaria Travel – Testing
Previous malaria antibody testing performed? Malarial antibody test result date (Start date of deferral) D D / M M / Y Y Y Y
Has the donor returned to a malarial area since last antibody test? Is it >120 days since return from travel? Haemoglobin – Testing
Donor Height
Blood pressure reading
Donor Weight
Note: Initials are only required if performed outside Assessment.
(As a guide, in the 3 hours before donating, at least 3 good-sized How many good-sized glasses of water/juice has the donor had in the last 3 hours? glasses of water/juice are recommended.) ARCBS-DAP-L3-026 | Version: 10 | Date Effective: 1 July 2012 | Page 6 of 6

Source: http://www.donateblood.com.au/files/pdfs/Donor%20Questionnaire%204%20July%202012.pdf