7Australian Capital Territory
Blood Donation (Transmittable
Diseases) Donor Form 2004
Disallowable Instrument DI2004—
Approved Form AF2004-
made under the
Blood Donation (Transmittable Diseases) Act 1985, s 10(3)
(Approved Forms)
I revoke disallowable instrument DI2003-255 and approved form
AF2003-10 notified on the ACT Legislation Register dated 28 August
2003.
I approve the attached blood donation donor declaration.
This instrument commences on 3 May 2004.
Simon Corbell MLA
Minister for Health
April 2004
FOR MORE INFORMATION, PLEASE CALL 13 14 95
OR VISIT donateblood.com.au
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.
All donations of blood are tested for the presence of hepatitis
B and C, HIV (AIDS virus), syphilis and HTLV. Should your
blood test positive or show a significant abnormal result you
will be notified.
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 meal in the hours before donating.
• You should fill in the declaration section but
don’t sign until you are interviewed!
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.
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.
ARCBS-NAT-DAP-L3-026 Version: 0.0.3 Date Effective: 3-May-2004 Page 1 of 6
Welcome to a
special, select group
of people who care
Donor Questionnaire
INFORMATION ABOUT DONATING BLOOD
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
Blood is rich in iron, some of which is lost each time you
donate. This is why we recommend 12 weeks between whole
blood 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 a while 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.
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 arm 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.
• Drink plenty of fluids.
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. If you’re driving, slow down and stop
the car where it is safe to do so.
Blood donation
is extremely safe
ARCBS-NAT-DAP-L3-026 Version: 0.0.3 Date Effective: 3-May-2004 Page 2 of 6
SECTION A – NEW AND RETURNED DONORS
Have you:
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. Ever spent more than 3 months in Central or South America? Yes _ No _ B8
18. Ever had treatment with the medication TIGASON (Etretinate) Yes _ No _ B9
or NEOTIGASON (Acitretin)?
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 in the relevant box like this _. Do not circle.
ARCBS-NAT-DAP-L3-026 Version: 0.0.3 Date Effective: 3-May-2004 Page 3 of 6
x
SECTION B – MEDICAL QUESTIONNAIRE
ALL donors please complete this section
Please respond by placing a cross in the relevant box like this _. Do not circle.
Today:
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 investigated or treated for any illness or had surgery? 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? 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. Have you lived in, or visited
• England, Scotland, Wales, Northern Ireland, the Channel Islands, Yes _ No _ D9
or the Isle of Man for a cumulative (total) period of six months or more,
between 1st January 1980 and 31st December 1996 inclusive?
ARCBS-NAT-DAP-L3-026 Version: 0.0.3 Date Effective: 3-May-2004 Page 4 of 6
x
SECTION C – DONOR DECLARATION
To the best of your knowledge have you:
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 Yes _ No _ F5
or acupuncture?
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
ARCBS-NAT-DAP-L3-026 Version: 0.0.3 Date Effective: 3-May-2004 Page 5 of 6
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.
ALL donors please complete this section
Please respond by placing a cross in the relevant box like this _. Do not circle. x
SECTION C – DONOR DECLARATION (continued)
Donor (please print)
Surname ........................................................................................
Given Name ...................................................................................
Date of birth ..................................................................................
(DD/MM/YY)
Signature .......................................................................................
Date ...............................................................................................
(DD/MM/YY)
Witness (please print)
Donor identity verified _
Supplementary questions asked Yes _ N/A _
Surname ........................................................................................
Given Name ...................................................................................
Signature .......................................................................................
Date ...............................................................................................
(DD/MM/YY)
Donation number
Please sign in the presence of the interviewer
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, or in some circumstances, for teaching,
research, quality assurance or the making of essential
diagnostic reagents.
You may be asked by the Blood Service to undergo further tests.
A part of your donation may be stored for future testing and
research. Approval from the appropriate Human Research Ethics
Committee must be obtained before any research is undertaken
on blood samples.
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.
ARCBS-NAT-DAP-L3-026 Version: 0.0.3 Date Effective: 3-May-2004 Page 6 of 6
Declaration
I agree to have blood taken from me under these conditions.
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.