Enterprise Management Blood System

DONATION IDENTIFICATION
NUMBER

BLOOD DONATION RECORD
SECTION I -

Womack Army Medical Center - Blood Donor Ctr

1. DONATION FACILITY

BRG-DRV0000647

SECTION II

2. DON/PROC

3. TODAY'S DATE

AU/WB

04/14/2014

7.NAME (Last, First, Middle Initial)

4. ID TYPE

8. GRADE/RATE

ACG-AUTOLOGOUS, DONOR

6. CHAGAS

13. ABO/Rh

9. DATE OF BIRTH

10. AGE

11. SEX

01/01/1980

34 Yr 3 Mo

F

14. CURRENT MAILING ADDRESS

15. COUNTRY

123 TEST LANE, ALEXANDRIA, VA, 22304

United States

18. ORGANIZATION

5. ID NUMBER

16. DUTY PHONE

12. ETHNICITY

17. BEST CONTACT PHONE

19. STATION

20. Total Donations

21. DONOR ID

2

SECTION III

22. DEFERRAL
LIST CHECKED BY

23. DONOR ID
VERIFIED BY

24 WEIGHT

ACA001

ACA001

160

31.VITAL SIGNS MONITOR

YES

NO

26. PULSE

27. BP

28. HGB/HCT

29. ARM CHECK

98

66

120/80

14 / 41

SAT

TECH:

TECH:

TECH:

TECH:

TECH:

ACA001

ACA001

ACA001

ACA001

ACA001

32. HEMOGLOBINOMETER

34. DOES DONOR QUALIFY?

DN00000021

25. TEMP

30. GENERAL
APPEARANCE
SAT

33. SCALE

35. BAG LOT NO.

36. SEGMENT NO.

37. REVIEWER

TECH:

DONOR MEDICAL HISTORY
Question # Question

Response

Comment

101

Are you pregnant now, or have you been pregnant in the past 6
weeks?

Yes

Reviewed and Verified
by Screener

Are you feeling well and healthy today?

No

103

104

106

Have you read and do you understand all the donor information
presented to you, and have your questions been answered?

No

Have you ever given blood under another name or Social Security
Number?

Yes

EDU1

IDENT

Have you ever been refused as a blood donor or told not to donate
blood?

Yes

Have you had any illness or infection in the last 14 days?

Yes

109

ILL2A

Have you ever had yellow jaundice, liver disease, hepatitis, or a
positive test for hepatitis?

Yes

Have you ever had chest pain, heart disease, or lung disease?

Yes

NHVH

112

114

In the past 4 weeks, have you taken any pills or medications or had any Yes
injections?
ABIO

Reviewed and Verified
by Screener

Donor ill in the last 14
days - Eligible

Are you taking any iron medications?

Do you have a consult from your Provider?

39. STOP TIME

40. PHLEBOTOMIST

Reviewed and Verified
by Screener
Reviewed and Verified
by Screener

Non-Viral Hepatitis

Medically Acceptable
Heart/Lung Condition
History of Fainting,
Convulsions, Seizures Eligible

Yes

Reviewed and Verified
by Screener

Smallpox Exposure No
Signs/Symptoms

Yes

Reviewed and Verified
by Screener

42. REACTION

UNSUCCESSFUL

INCOMPLETE

Reviewed and Verified
by Screener

Reviewed and Verified
by Screener

Consult Date

41. DONATION STATUS
COMPLETE

Reviewed and Verified
by Screener

Reviewed and Verified
by Screener

Taking Iron Meds

In the past 8 weeks, have you received a smallpox vaccination or have Yes
you had close contact with the vaccination site of anyone else?
POX

38. START TIME

Radiology Procedure Eligible

Donor is taking an
antibiotic, no cause for
deferral.

DATE

SECTION IV

Reviewed and Verified
by Screener

Yes

IRON
113

Reviewed and Verified
by Screener

Donor has alternate
identity.

E

Have you ever had fainting spells, convulsions or seizures?

FCSA

111

Reviewed and Verified
by Screener

Donor has read and
understands
education materials.

Are you scheduled for any procedure in Radiology today or tomorrow? Yes

HLCA

110

Reviewed and Verified
by Screener

Donor misunderstood.
Meant to answer YES.

Donor told not to
donate - Eligible

REFA

RADA

108

History of pregnancy
within last 6 weeks.

PL

107

WELL

M

105

SA

102

PREG

OVERFILL

NONE

SLIGHT
MODERATE

SEVERE