Blood Donor History Questionnaire

Attachment 1: Blood Donor History Questionnaire to be evaluated

The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222).

OMB #0920-0222; Expiration Date: 03/31/2013

Full-Length Donor History Questionnaire

	Yes	No
Are you
Feeling healthy and well today?		
Currently taking an antibiotic?		
Currently taking any other medication for an infection?		
Please read the Medication Deferral List.
Are you now taking or have you ever taken any medications on the Medication Deferral List?		
Have you read the educational materials?		
In the past 48 hours
Have you taken aspirin or anything that has aspirin in it?		
In the past 6 weeks
Female donors: Have you been pregnant or are you pregnant now? (Males: check “I am male.”)			 I am male
In the past 8 weeks have you
Donated blood, platelets or plasma?		
Had any vaccinations or other shots?		
Had contact with someone who had a smallpox vaccination?		
In the past 16 weeks
Have you donated a double unit of red cells using an apheresis machine?		

In the past 12 months have you
Had a blood transfusion?		
Had a transplant such as organ, tissue, or bone marrow?		
Had a graft such as bone or skin?		
Come into contact with someone else’s blood?		
Had an accidental needle-stick?		
Had sexual contact with anyone who has HIV/AIDS or has had a positive test for the HIV/AIDS virus?		
Had sexual contact with a prostitute or anyone else who takes money or drugs or other payment for sex?		
Had sexual contact with anyone who has ever used needles to take drugs or steroids, or anything not prescribed by their doctor?		
Had sexual contact with anyone who has hemophilia or has used clotting factor concentrates?		
Female donors: Had sexual contact with a male who has ever had sexual contact with another male? (Males: check “I am male.”)			 I am male
Had sexual contact with a person who has hepatitis?		
Lived with a person who has hepatitis?		
Had a tattoo?		
Had ear or body piercing?		
	Yes	No
Had or been treated for syphilis or gonorrhea?		
Been in juvenile detention, lockup, jail, or prison for more than 72 hours?		
In the past three years have you
Been outside the United States or Canada?		
From 1980 through 1996,
Did you spend time that adds up to three (3) months or more in the United Kingdom? (Review list of countries in the UK)		
Were you a member of the U.S. military, a civilian military employee, or a dependent of a member of the U.S. military?		
From 1980 to the present, did you
Spend time that adds up to five (5) years or more in Europe? (Review list of countries in Europe.)		
Receive a blood transfusion in the United Kingdom or France? (Review list of countries in the UK.)		
From 1977 to the present, have you
Received money, drugs, or other payment for sex?		
Male donors: had sexual contact with another male, even once? (Females: check “I am female.”)			 I am female

Have you EVER
Had a positive test for the HIV/AIDS virus?		
Used needles to take drugs, steroids, or anything not prescribed by your doctor?		
Used clotting factor concentrates?		
Had hepatitis?		
Had malaria?		
Had Chagas’ disease?		
Had babesiosis?		
Received a dura mater (or brain covering) graft?		
Had any type of cancer, including leukemia?		
Had any problems with your heart or lungs?		
Had a bleeding condition or a blood disease?		
Had sexual contact with anyone who was born in or lived in Africa?		
Been in Africa?		
Have any of your relatives had Creutzfeldt-Jakob disease?		

Use this area for additional questions	Yes	No

MEDICATION DEFERRAL LIST

Please tell us if you are now taking or if you have EVER taken any of these medications:

• Proscar© (finasteride)  usually given for prostate gland enlargement

• Avodart©, Jalyn (dutasteride)  usually given for prostate enlargement

• Propecia© (finasteride)  usually given for baldness

• Accutane© (Amnesteem, Claravis, Sotret, isotretinoin)  usually given for severe acne

• Soriatane© (acitretin) – usually given for severe psoriasis

• Tegison© (etretinate) – usually given for severe psoriasis

• Growth Hormone from Human Pituitary Glands  used usually for children with delayed

or impaired growth

• Insulin from Cows (Bovine, or Beef, Insulin)  used to treat diabetes

• Hepatitis B Immune Globulin – given following an exposure to hepatitis B.

NOTE: This is different from the hepatitis B vaccine which is a series of 3 injections

given over a 6 month period to prevent future infection from exposures to hepatitis B.

• Plavix (clopidogrel) and Ticlid (ticlopidine) – inhibits platelet function; used to reduce the chance for heart attack and stroke.

• Feldene – given for mild to moderate arthritis pain

• Experimental Medication or Unlicensed (Experimental) Vaccine – usually associated with a research protocol

IF YOU WOULD LIKE TO KNOW WHY THESE MEDICINES AFFECT YOU AS A BLOOD DONOR, PLEASE KEEP READING:

• If you have taken or are taking Proscar, Avodart, Jalyn, Propecia, Accutane, Soriatane, or Tegison, these medications can cause birth defects. Your donated blood could contain high enough levels to damage the unborn baby if transfused to a pregnant woman. Once the medication has been cleared from your blood, you may donate again. Following the last dose, the deferral period is one month Proscar, Propecia and Accutane, six months for Avodart and Jalyn, and three years for Soriatane. Tegison is a permanent deferral.

• Growth hormone from human pituitary glands was prescribed for children with delayed or impaired growth. The hormone was obtained from human pituitary glands, which are found in the brain. Some people who took this hormone developed a rare nervous system condition called Creutzfeldt-Jakob Disease (CJD, for short). The deferral is permanent.

• Insulin from cows (bovine, or beef, insulin) is an injected material used to treat diabetes. If this insulin was imported into the US from countries in which “Mad Cow Disease” has been found, it could contain material from infected cattle. There is concern that "Mad Cow Disease" is transmitted by transfusion. The deferral is indefinite.

• Hepatitis B Immune Globulin (HBIG) is an injected material used to prevent infection following an exposure to hepatitis B. HBIG does not prevent hepatitis B infection in every case, therefore persons who have received HBIG must wait 12 months to donate blood to be sure they were not infected since hepatitis B can be transmitted through transfusion to a patient.

• Feldene is a non-steroidal anti-inflammatory drug that can affect platelet function. A donor taking Feldene will not be able to donate platelets for 2 days; however, its use will not affect whole blood donations.

• Plavix and Ticlid are medications that can decrease the chance of a heart attack or stroke in individuals at risk for these conditions. Since these medications can affect platelets, anyone taking Plavix or Ticlid will not be able to donate platelets for 14 days after the last dose. Use of either medication will not prohibit whole blood donations.

• Experimental Medication or Unlicensed (Experimental) Vaccine is usually associated with a research protocol and the effect on blood donation is unknown. Deferral is one year unless otherwise indicated by Medical Director.

Blood Donor Educational Materials:

MAKING YOUR BLOOD DONATION SAFE

Thank you for coming in today! This information sheet explains how YOU can help us make the donation process safe for yourself and patients who might receive your blood. PLEASE READ THIS INFORMATION BEFORE YOU DONATE! If you have any questions now or anytime during the screening process, please ask blood center staff.

ACCURACY AND HONESTY ARE ESSENTIAL!

Your complete honesty in answering all questions is very important for the safety of patients who receive your blood. All information you provide is confidential.

DONATION PROCESS:

To determine if you are eligible to donate we will:

-Ask questions about health, travel, and medicines

-Ask questions to see if you might be at risk for hepatitis, HIV, or AIDs

- Take your blood pressure, temperature and pulse

- Take a small blood sample to make sure you are not anemic

If you are able to donate we will:

- Cleanse your arm with an antiseptic. (If you are allergic to Iodine, please tell us!)

-Use a new, sterile, disposable needle to collect your blood

DONOR ELIGIBILITY – SPECIFIC INFORMATION

Why we ask questions about sexual contact:

Sexual contact may cause contagious diseases like HIV to get into the bloodstream and be spread through transfusions to someone else.

Definition of “sexual contact”:

The words “have sexual contact with” and “sex” are used in some of the questions we will ask you, and apply to any of the activities below, whether or not a condom or other protection was used:

1. Vaginal sex (contact between penis and vagina)

2. Oral sex (mouth or tongue on someone’s vagina, penis, or anus)

3. Anal sex (contact between penis and anus)

HIV/AIDS RISK BEHAVIORS AND SYMPTOMS

AIDS is caused by HIV. HIV is spread mainly through sexual contact with an infected person OR by sharing needles or syringes used for injecting drugs.

DO NOT DONATE IF YOU:

-Have AIDS or have ever had a positive HIV test

-Have ever used needles to take drugs, steroids, or anything not prescribed by your doctor

- Are a male who has had sexual contact with another male, even once, since 1977

- Have ever taken money, drugs or other payment for sex since 1977

- Have had sexual contact in the past 12 months with anyone described above

- Have had syphilis or gonorrhea in the past 12 months

- In the last 12 months have been in juvenile detention, lockup, jail or prison for more than 72 hours

-Have any of the following conditions that can be signs or symptoms of HIV/AIDS:

Unexplained weight loss or night sweats

Blue or purple spots in your mouth or skin

Swollen lymph nodes for more than one month

White spots or unusual sores in your mouth

Cough that won’t go away or shortness of breath

Diarrhea that won’t go away

Fever of more than 100.5 ^oF for more than 10 days

Remember that you CAN give HIV to someone else through blood transfusions even if you feel well and have a negative HIV test. This is because tests cannot detect infections for a period of time after a person is exposed to HIV. If you think you may be at risk for HIV/AIDS or want an HIV/AIDS test, please ask for information about other testing facilities. PLEASE DO NOT DONATE TO GET AN HIV TEST!

Travel to or birth in other countries

Blood donor tests may not be available for some contagious diseases that are found only in certain countries. If you were born in, have lived in, or visited certain countries, you may not be eligible to donate.

What happens after your donation:

To protect patients, your blood is tested for hepatitis B and C, HIV, certain other infectious diseases, and syphilis. If your blood tests positive it will not be given to a patient. You will be notified about test results that may disqualify you from donating in the future. Please do not donate to get tested for HIV, hepatitis, or any other infections!

Thank you for donating blood today!

(Donor Center Name)

(Telephone Number)

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