Donor Questionnaire

Welcome to a
special, select group
of people who care

Thank you for coming to give blood today. Your donation could save the life of someone or help
them through an operation.

The Australian Red Cross Blood Service is committed to the provision of safe blood and blood products to those who need them.

The Donation Process
We are going to ask you to answer some questions about your general health to help us to decide firstly 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 the reasons for some of the questions may be difficult to understand.  Please discuss them with the member of staff who will be interviewing you. We are committed to keeping your answers and anything you tell us in the interview CONFIDENTIAL, in so far as we are able.

Even though there are a lot of questions you need to answer them honestly and to the best of your ability. Answering these questions honestly is important because 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 B, hepatitis C, HIV, HTLV and syphilis.  Should your blood test positive or show a significantly abnormal result, you will be notified.  However, on some occasions laboratory testing cannot be performed and in these instances, your donation will not be used.

You have an option to change your mind about  donating blood at any time. Please indicate to staff if at any time during the donation process you wish to leave.

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 form and you will need to complete a new form.

On the Day
•	Drink up! - have 3 or 4 glasses of water or juice in the hours before you donate.
•	Eat! - have a good sized breakfast or lunch.
•	You should fill in the declaration section but don’t sign until you have completed the interview!

Privacy Statement
The personal information collected on this form allows ARCBS to register and retain you as a blood donor.  All information collected will be handled in the strictest confidence in accordance with the Federal Privacy Act.  For more information, please ask for a Privacy brochure

For more information call 13 14 95 or visit us at www.donateblood.com.au

INFORMATION ABOUT 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 ever occur, you will know some simple and appropriate steps to take.
Please note: All equipment used in blood collection is sterile, used once only and discarded.
How to avoid bruising
Try to limit use of the arm from which the blood was taken for the first 15 minutes after donating.
If you develop a bruise that causes discomfort, a mild pain reliever (not aspirin) or an icepack may help.
Please phone us if a troublesome bruise occurs. Such bruises are not common and we want to hear about them as we may be able to give helpful advice.
Bleeding from the needle site
If this happens after a donation has been collected:
•	Lift your arm above your shoulder, keep your elbow straight and press on the bleeding site.
•	Sit down and ask a staff member for assistance.
You can avoid bleeding by:
•	Limiting the use of the elbow for about 15 minutes.
•	Being careful when using your arm to eat or drink and when putting on a jacket after donating.
Feeling faint
Fainting is due to a nerve reflex, which slows the pulse and lowers blood pressure for a short period.
If you feel dizzy, lightheaded, or unwell and are still on the donor couch, tell a staff member immediately.
•	Rest for around 30 minutes or until you feel well again.
•	A drink of cold fluids is helpful.
If you feel faint after you have left the donor couch, sit or lie down as flat as possible rather than take the risk of falling.
If you have left the blood collection centre then follow the recommendations above and if you’re driving, slow down and stop the car where it is safe to do so.
Reducing the chance of fainting
Make sure that you eat something in the 3 hours before donating and drink 4 glasses of water/juice prior to visiting the blood collection centre.
In warm weather, be prepared by having plenty of liquid in the 24 hours before donation.
•	Avoid strenuous exercise and drink plenty of liquid (preferably non-alcoholic) in the few hours after your donation.
•	If you have a naturally low blood pressure and feel faint when you stand up suddenly, please tell us.
•	Are you very anxious? Please let us know. We can help you feel at ease.
Rare events
Rarely a donation needle may irritate a nerve under the skin.  This may be painful but is normally only momentary. If this persists or you have any concerns, please speak to a member of the donor team, or if after leaving the venue you require medical attention, please contact a doctor, and notify your local blood service.
Very rarely, donors may develop a fast pulse or a sensation of tightness in the chest. If this happens, tell a staff member immediately.
If you notice a problem after leaving the blood collection centre, contact a hospital or doctor so the problem can be assessed. Please contact us later and tell us what happened.
Keeping your blood healthy – iron stores
Whole blood is rich in iron, some of which is lost each time you donate. This is why we recommend 12 weeks between donations to allow the iron to be replaced.
We measure your haemoglobin each time you donate, but this is not a perfect indicator of iron levels. 
As iron can be low and the haemoglobin test still acceptable, it is important that you have a diet containing plenty of iron, even if your haemoglobin is satisfactory. Please ask for our brochure titled “Why Iron And Haemoglobin Are Important” 
After giving blood, please stay at least 15 minutes and have some refreshments. 
Should you become aware of any reason why your blood should not be used for transfusion, 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.

SECTION 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 tick in the relevant box.  Do not circle.
Have you:	Comments
			(Staff Use Only)
1.	Ever volunteered to donate blood before? 	Yes ¨ No ¨	NP
	If yes – where? ........................................................................................
	when? ......................................................................................................	
2.	Ever been advised not to give blood? 	Yes ¨ No ¨	NP
	
3.	Ever suffered from anaemia or any blood disorder? 	Yes ¨ No ¨	A4
	
4.	Ever had a serious illness, operation or been admitted to hospital? 	Yes ¨ No ¨	A5
	
5.	Had a neurosurgical procedure involving head, brain 	Yes ¨ No ¨	A6
	or spinal cord between 1972 and 1989?
	
6.	Ever received a transplant or graft (organ, cornea, dura mater, bone etc.)? 	Yes ¨ No ¨	A7
	
7.	Received injections of human growth hormone for short stature 	Yes ¨ No ¨	A8
	or human pituitary hormone for infertility prior to 1986?
	
8.	Ever suffered head injury, stroke or epilepsy? 	Yes ¨ No ¨	A9
	
9.	Ever had a heart or blood pressure problem, rheumatic fever 	Yes ¨ No ¨	B0
	or heart murmur or chest pain?
	
10.	Ever had a bowel disease, stomach or duodenal problems or ulcers? 	Yes ¨ No ¨	B1
	
11.	Ever had kidney, liver or lung problems including tuberculosis (TB)?	Yes ¨ No ¨	B2
	
12.	Ever had diabetes, a thyroid disorder or an autoimmune disease 	Yes ¨ No ¨	B3
	e.g. rheumatoid arthritis or lupus?
	
13.	Ever had cancer of any kind including melanoma? 	Yes ¨ No ¨	B4
	
14.	Ever had malaria, Ross River fever, Q fever, leptospirosis or Chagas’ disease? 	Yes ¨ No ¨	B5
	
15.	Ever had (yellow) jaundice or hepatitis? 	Yes ¨ No ¨	B6
	
16.	Travelled or lived overseas in the last 3 years?	Yes ¨ No ¨	B7
	
17.	What was your country of birth?		B8
	
18.	Have you ever had treatment with the medication TIGASON (Etretinate)	Yes ¨ No ¨	B9
	or NEOTIGASON (Acitretin)?

SECTION B – MEDICAL QUESTIONNAIRE
ALL donors please complete this section
Please respond by placing a cross or tick in the relevant box.  Do not circle.
Today: 	Comments
			(Staff Use Only)
1. 	Are you feeling healthy and well? 	Yes ¨ No ¨	C0
	
2. 	Women only – Are you pregnant or breast-feeding or have you been 	Yes ¨ No ¨	C1
	pregnant in the past 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, 	Yes ¨ No ¨	C2
	underwater diving, piloting a plane or other activities? 
	
In the last week have you:
4. 	Had dental work, cleaning, fillings or extractions? 	Yes ¨ No ¨	C4
	
5. 	Taken any aspirin, pain killers or anti-inflammatory preparations? 	Yes ¨ No ¨	C5
	
6. 	Had any cuts, abrasions, sores or rashes? 	Yes ¨ No ¨	C6
	
7. 	Had a gastric upset, diarrhoea, abdominal pain or vomiting? 	Yes ¨ No ¨	C7
	
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? 	Yes ¨ No ¨	C9
	
9.	Had chest pain/angina or an irregular heartbeat? 	Yes ¨ No ¨	D0
	
10.	Taken tablets for acne or a skin condition? 	Yes ¨ No ¨	D1
	
11.	Taken any other medication, including regular medication?	Yes ¨ No ¨	D2
	
12.	Worked in an abattoir? 	Yes ¨ No ¨	D3
	
13.	Been overseas?	Yes ¨ No ¨	D4
	
14.	Had a sexually transmitted disease e.g. gonorrhoea, syphilis or herpes? 	Yes ¨ No ¨	D5
	
15.	Had any immunisations/vaccinations? 	Yes ¨ No ¨	D6
	
16.	Had shingles or chickenpox? 	Yes ¨ No ¨	D7
	
17.	Do you know of anyone in your family who had or has:
	• Creutzfeldt-Jakob disease (CJD)? 	Yes ¨ No ¨ 	D8
	• Gerstmann-Straussler-Scheinker syndrome (GSS)? 	Yes ¨ No ¨ 	D8
	• Fatal Familial Insomnia (FFI)? 	Yes ¨ No ¨ 	D8
	
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 or the Isle of Man?
		Yes ¨ No ¨	D9

SECTION C – DONOR DECLARATION 
ALL donors please complete this section
Please respond by placing a cross or tick in the relevant box. Do not circle.

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 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.

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.

To the best of your knowledge have you: 	Comments
			(Staff Use Only)
1.	In the last 6 months, had an illness with swollen glands and a rash, 	Yes ¨ No ¨ E1
	with or without a fever?
	
2.	Ever thought you could be infected with HIV or have AIDS? 	Yes ¨ No ¨ E2
	
3.	Ever “used drugs” by injection or been injected, even once, 	Yes ¨ No ¨ E3
	with drugs not prescribed by a doctor or dentist?
	
4.	Ever had treatment with clotting factors such as Factor VIII or Factor IX? 	Yes ¨ No ¨ E4
	
5.	Ever had a test which showed you had hepatitis B, hepatitis C, HIV or HTLV? 	Yes ¨ No ¨ E5
	
6.	In the last 12 months engaged in sexual activity with someone 	Yes ¨ No ¨ E6
	you might think would answer “yes” to any of questions (1-5)?
	
7.	Since your last donation or in the last 12 months, had sexual activity 	Yes ¨ No ¨ E7
	with a new partner who currently lives or has previously lived overseas?
	
Within the last 12 months have you:
8.	Had male to male sex? 	Yes ¨ No ¨ E9
	
9.	Had sexual activity with a male who you think might be bisexual? 	Yes ¨ No ¨ F0
	
10.	Been a male or female sex worker 	Yes ¨ No ¨ F1
	(e.g. received payment for sex in money, gifts or drugs)?
	
11.	Engaged in sexual activity with a male or female sex worker? 	Yes ¨ No ¨ F2
	
12.	Been injured with a used needle (needlestick)?	Yes ¨ No ¨ F3
	
13.	Had a blood/body fluid splash to eyes, mouth, nose or to broken skin? 	Yes ¨ No ¨ F4
	
14.	Had a tattoo (including cosmetic tattooing), skin piercing, electrolysis 
		or acupuncture?	Yes ¨ No ¨ F5
	
15.	Been imprisoned in a prison or lock-up? 	Yes ¨ No ¨ F6
	
16.	Had a blood transfusion? 	Yes ¨ No ¨ F7
	
17.	Had (yellow) jaundice or hepatitis or been in contact with someone who has? 	Yes ¨ No ¨ F8

SECTION C – DONOR DECLARATION (Continued)

This declaration is to be signed in the
presence of a Blood Service staff member.
(Please read the following statements)

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. A part of your donation may also be stored for future testing and research. 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.

OFFICE USE ONLY
Witness (please print)
Donor identity verified  	¨

Supplementary questions answered Yes	¨ N/A ¨

Surname/Family Name ................................…...........

Given Name ...............................................…….........

Signature ...........................................Category ……..

Time…………………… Date ……………….………….
	(DD/MM/YY)	

Donation number

Should you become aware of any reason why your blood should not be used for transfusion, 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.

Declaration
I agree to have blood taken from me under these conditions. 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 have been advised that there are some possible risks associated with donating blood and that I must follow the instructions of the Blood Service staff to minimise these risks.

Donor (please print)
Surname/Family Name 	

Given Name 	

Date of birth 	
		(DD/MM/YY)

Please ONLY sign in the presence of the interviewer

Signature 	

Date .