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F020831 pg 1 2011-05-01 revised 2011-05-09

RECORD OF DONATION
ANSWER YES OR NO TO QUESTIONS 1 THROUGH 13, FILL IN 1. a) Are you feeling well today? .
b) Do you have a cold, flu, sore throat, fever, infection or allergy problem today? .
2. a) In the last 3 days have you taken any medicine or drugs (pills including Aspirin or shots), other than birth control pills b) In the last 3 days have you had dental work? .
3. In the last month have you had an AIDS (HIV) test other than for donating blood? .
4. a) In the last 3 months have you had a vaccination? . b) In the last month have you taken Accutane, Clarus (isotretinoin), Toctino (alitretinoin), Proscar, Propecia (finasteride), 5. a) In the last 6 months have you been under a doctor’s care or had surgery? .
b) If female, in the last 6 months have you been pregnant? .
c) In the last 6 months have you taken Avodart, Jalyn (dutasteride) or Methotrexate? .
d) In the last 6 months have you had a tattoo, ear or skin piercing, acupuncture or electrolysis? .
e) In the last 6 months have you had an injury from a needle or come in contact with someone else’s blood? .
6. a) In the last 12 months have you had a rabies shot or a graft? .
b) In the last 12 months have you had close contact with a person who has had hepatitis or yellow jaundice? .
c) In the last 12 months have you been in jail or prison? .
7. a) In the last 12 months have you travelled outside Canada or the U.S. and stayed less than 6 months?.
b) In the last 3 and a half years have you spent more than 6 months in a continuous period outside Canada or the U.S.? .
8. a) Since 1980, did you receive a blood transfusion or blood product in the United Kingdom, France or elsewhere in Europe? b) Have you spent a total of 3 months or more in the United Kingdom (England, Northern Ireland, Scotland, Wales, the Isle of Man, or the Channel Islands) from January 1, 1980 through December 31, 1996? .
c) Have you spent a total of 3 months or more in France from January 1, 1980 through December 31, 1996? .
d) Have you spent a total of 6 months or more in Saudi Arabia from January 1, 1980 through December 31, 1996? .
e) Have you spent a total of 5 years or more in Europe since January 1, 1980? .
9. Have you ever had malaria? .
10. a) Have you ever taken Tegison or Soriatane for skin problems? .
b) Have you ever taken human pituitary growth hormone or received a dura mater (brain covering) graft ?.
11. Have you ever had: a) yellow jaundice (other than at birth) or hepatitis? .
b) epilepsy, coma, stroke or fainting? .
c) cancer, diabetes or Crohn’s disease? .
d) heart, kidney, lung or blood problems? .
e) Chagas’ disease, babesiosis or leishmaniasis? .
12. Are you aware of a diagnosis of Creutzfeldt-Jakob Disease among any of your blood relatives (parent, child, sibling)? .
13. Have you, in your past or present job, taken care of or handled monkeys or their body fluids? .
STOP HERE
14. a) Have you spent a total of 6 months or more in a continuous period in Mexico, Central America or South America? . b) Were you born in Mexico, Central America or South America? .
c) Was your mother or grandmother born in Mexico, Central America or South America? .
15. Do you have AIDS or have you ever tested positive for HIV/AIDS? .
16. Have you used cocaine within the last 12 months? .
17. Have you taken illegal steroids by needle in the last 12 months? .
18. At any time since 1977, have you taken money or drugs for sex? .
19. Male donors: Have you had sex with a man, even one time since 1977? .
20. Have you ever taken illegal drugs with a needle, even one time? .
21. Have you ever taken clotting factor concentrates for a bleeding disorder such as hemophilia? .
22. Have you had sex with anyone who has AIDS or has tested positive for HIV or AIDS? .
23. Female donors: In the last 12 months, have you had sex with a man who had sex, even one time since 1977 with 24. Have you had sex in the last 12 months with anyone who has ever taken illegal drugs or illegal steroids with a needle? .
25. At any time in the last 12 months, have you paid money or drugs for sex? .
26. At any time in the last 12 months, have you had sex with anyone who has taken money or drugs for sex? .
27. Have you had sex in the last 6 months with anyone who has taken clotting factor concentrates? .
28. In the last 12 months, have you had or been treated for syphilis or gonorrhea? .
29. In the last 12 months, have you received blood or blood products by transfusion for any reason, 30. In the past 6 months, have you had sex with someone whose sexual background you don’t know? .
31. a) Were you born in or have you lived in Africa since 1977?. b) Since 1977, did you receive a blood transfusion or blood product in Africa?. c) Have you had sexual contact with anyone who was born in or lived in Africa since 1977? .
I have answered all questions truthfully. I understand that to make a false statement is a serious matter and could associated with my whole blood or automated donation. I have read and understand the information on how the AIDS (HIV) virus may spread by donated blood and plasma. I agree not to make a donation if there is a chance this might spread the AIDS (HIV) virus. I agree to my donation being tested for HIV, hepatitis and other infections and that my positive test results will be given to me. I agree to donate blood for use as decided by Canadian Blood Services. I agree to call Canadian Blood Services if after donating I decide my blood should not be used. Donor’s Signature:________________________________________________________ Donor Accepted: Date: __________________________________________________________________ F020831 2011-09-01

Source: http://www.timwiebe.net/GVCBiology/BloodDonor_files/Donor%20Questionnaire.pdf

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