Enterprise Management Blood System

DONATION IDENTIFICATION
NUMBER

BLOOD DONATION RECORD
SECTION I – (Donor Drive Details taken from Drive ID connected to Donor during Registration)
1. DONATION FACILITY

SECTION II (to be completed by blood donor) 
6. NAME (Last, First, Middle Initial)

2. TODAY’S DATE

7. GRADE/RATE

3. ID TYPE

4. ID NUMBER

8. DATE OF BIRTH

9. AGE

10. SEX

M
14. CURRENT MAILING ADDRESS (Street, City, State, Zip Code)

15. COUNTRY

18. ORGANIZATION

11. ETHNIC
ORIGIN

donor center personnel)

21. DEFERRAL
LIST CHECKED BY

22. DONOR ID
VERIFIED BY

12. ABO/Rh

13. DONOR CATEGORY

Mil

16. DUTY PHONE (Include Area Code)

19. STATION

SECTION III – (to be completed by

Dep

20. QUESTION SET

23. WEIGHT

24. TEMP

25. PULSE

TECH:

TECH:
TECH:
31. SCALE

30. HEMOGLOBINOMETER

33. DONATION
TYPE

34. INTENDED
RECIPIENT

Civ

17. BEST CONTACT PHONE (Include Area Code)

26. BP

27. HGB/HCT

28. ARM CHECK
SAT

29. VITAL SIGNS MONITOR

32. GENERAL
APPEARANCE

F

5. ID STATE/COUNTRY?

35. FMP/SSN

36. TOTAL
DONATIONS

UNSAT

TECH:

37. HOSPITAL TRANSFUSION SITE

38. SURGERY DATE

42. ANTI-COAGULANT

43. REVIEWER

SAT UNSAT
39. DOES DONOR QUALIFY?
YES

NO

40. BAG LOT NO.

41. SEGMENT NO.

TECH: _______

DONOR MEDICAL HISTORY (Indicate “Y” for Yes or “N” for No)
1

3

Are you currently taking any other medication for an infection?

4

Please read the Medication Deferral List. Are you now taking or have
you ever taken any medications on the Medication Deferral List?

5

Have you read the educational materials?

Y N

6

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?

Y N

8

28

In the past three years, have you been outside the
United States or Canada?

Y N

29

Y N

Y

N

Did you spend time that adds up to three (3) months or more in
the United Kingdom? (Review list of countries in the U.K.)

Y

N

30

Were you a member of the U.S. military, a civilian military
employee, or a dependent of a member of the U.S. military?

Y

N

31

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 U.K.)
FROM 1977 TO THE PRESENT, HAVE YOU

Y

N

Y

N

Y N

M

7

SA

Y N

2

Are you feeling healthy and well today?

Are you currently taking an antibiotic?

Y N

FROM 1980 THROUGH 1996

FROM 1980 TO THE PRESENT, DID YOU

32

Y N

In the past 8 weeks, have you had any vaccinations or other shots?
In the past 8 weeks, have you had contact with someone who had a
smallpox vaccination?

Y N
Y N

11

Y N

12

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?

Y N

35
36

13
14

Had a transplant such as organ, tissue, or bone marrow?
Had a graft such as bone or skin?

Y N
Y N

37
38

Used clotting factor concentrates?
Had Hepatitis?

Y
Y

N
N

15

Come into contact with someone else’s blood?

Y N

39

Had Malaria?

Y

N

16
17

Y N
Y N

40
41

Had Chagas disease?
Had Babesiosis?

Y
Y

N
N

Y N

42

Received a dura mater (or brain covering) graft?

Y

N

Y N

43

Had any type of cancer, including leukemia?

Y

N

Y N

44

Had any problems with your heart or lungs?

Y

N

Y N

45

Had a bleeding condition or a blood disease?

Y

N

22

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?

Y N

46

Have any of your relatives had Creutzfeldt-Jakob disease?

Y

N

23

Lived with a person who has Hepatitis?

Y N

47

Have you ever had a transfusion or ever been pregnant?

Y

N

24

Had a tattoo?

Y N

48

From 1980 to present, did you spend time in Saudi Arabia?

Y

N

25

Had ear or body piercing?

Y N

49

In the past 12 months, have you been under a doctor’s care for
an illness or surgery?

Y

N

26

Had or been treated for syphilis or gonorrhea?

Y N

Intentionally left blank

27

Been in juvenile detention, lockup, jail, or prison for more than 72 hours? Y N

Intentionally left blank

19
20
21

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

SECTION IV

41. START TIME

42. STOP TIME

43. PHLEBOTOMIST

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?

44. DONATION STATUS

45. REACTION

COMPLETE

NONE

UNSUCCESSFUL

INCOMPLETE

OVERFILL

Y N
Y N

Y N
Y N

E

18

33
34

PL

9
10

SLIGHT
MODERATE

SEVERE

SECTION V – DONOR MEDICAL HISTORY COMMENTS/DONOR REACTION COMMENTS (to be completed by Donor Center personnel)

SA

PL

M

Privacy Act Statement – AUTHORITY: 10 U.S.C. 136 (Assistant Secretaries of defense) and E.O. 9397.

PRINCIPAL PURPOSE(S): To record time of withdrawal and type of blood, and to determine suitability of voluntary blood donations. To administer the
Armed Services Blood Program, and, in some cases, to recommend medical treatment.
ROUTINE USE(S): None

E

DISCLOSURE: Voluntary; however, failure to provide complete information will make you ineligible to donate blood at this time.
Statement of Consent – It has been explained to me that blood donation is a voluntary process requiring the collection of approximately 450-500 mL of
blood. The collection time usually ranges from 5 to 10 minutes. Complications at the venipuncture site may include, but are not limited to: discomfort,
bruising, swelling, or infection. Other complications could include: fatigue, light-headedness, dizziness, nausea, vomiting, and/or fainting. On very rare
occasions, a more severe reaction may occur.
I have reviewed and understand the information provided to me regarding the spread of the AIDS virus (HIV) by blood and plasma. If I am potentially at
risk for spreading the virus known to cause AIDS, I agree not to donate any blood products for transfusion to another person or for further manufacture. I
understand that my blood will be tested for antibodies to HIV, Hepatitis B, Hepatitis C, and other disease markers. If this testing indicates that I should no
longer donate blood or plasma because of a risk of transmitting these viruses, my name will be entered on a list of permanently deferred donors. I
understand that I will be notified of positive results. For active duty personnel, reservists, and accessions, I understand positive screening and
confirmatory results will be forwarded to appropriate medical personnel for further evaluation, and if required “fitness for duty” determination. If instead, the
result of the testing is not clearly negative or positive, my blood will not be used and my name may be placed on a deferral list without my being informed
until the results are further clarified.
I understand there are rare circumstances, due to blood tubes not being collected or due to specimen acceptability, in which infectious disease testing may
not be performed on my blood.
I understand that if a computer assisted interview is completed, only the questions I have answered that require further information will be printed on this
form.
I have been given an opportunity to ask questions and have had a chance to refuse the phlebotomy procedure. My signature below indicates my consent
to have a phlebotomist collect blood from me today.
76. DONOR SIGNATURE. I have read the Privacy Act Statement and Statement of Consent above, and have been given the opportunity to ask questions relating to the educational material and
medical history questions.
________________________________________________________________________________________________________
Signature

_________________________
Date