Cherokee Trail High School Blood Drive. Please help us to save lives! February 14th. 8:00 to 9:40 am & 11:00 am to 1:30 pm Upper Lecture Center

Transcription

1 Cherokee Trail High School Blood Drive Please help us to save lives! February 14th 8:00 to 9:40 am & 11:00 am to 1:30 pm Upper Lecture Center To be eligible to donate you need to: weigh at least 110 pounds be at least 16-years-old & have signed Parental Consent form if you are 16 or 17 have not traveled to a malaria risk country in the past year eat a good meal and drink plenty of water before your donation receive teacher permission to donate during a class (cannot have an F in the class you will miss) bring your ID with you to the drive allow 1 hour to potentially save 3 lives! Questions? Contact Pam Graham ( ) or at pgraham3@cherrycreekschools.org It only takes about an hour to save up to 3 lives

2 Parental Acknowledgement Form CDO-013-PRD Acknowledgement from parent/guardian for minor to donate blood REV 11rev 18 ATTENTION MINOR AND PARENT/GUARDIAN: Please Read All Information on Front AND Back then Complete and Sign Form IMPORTANT FACTS FOR BLOOD DONORS REQUIRED ITEMS FOR MINOR TO BRING ON DAY OF DONATION If you are 16 or 17 years of age you must have the Parental Acknowledgment Form completely filled out and signed by your parent or guardian to be able to donate on the day of your drive. No matter your age, you must have some form of identification with you when you present to donate on the day of your drive. Examples of identification include but are not limited to: driver s license, work badge, school ID, credit card, mail, etc. LIFESAVING IMPACT OF BLOOD DONORS Giving blood and time makes you part of a local nonprofit mission and lifesaving cause. Nearly 8 percent of Bonfils blood collection comes from high school blood drives. Donating blood is an easy way to volunteer and save lives throughout the year. EATING AND DRINKING BEFORE AND AFTER DONATING BLOOD It is imperative that prior to your donation you eat within 2 hours and hydrate for hours so your donation process is smooth and you feel better during the process. After your donation it is also important to rest in our canteen area, have a snack and rehydrate so your body will have additional energy to compensate for your donation. PHYSICAL ACTIVITY AND SPORTS AFTER DONATING BLOOD Donating blood leads to a temporary decrease in the volume of oxygen-carrying red blood cells so strenuous activity after donation can lead to side effects like light-headedness or dizziness. Do not engage in strenuous activities such as lifting, running, pushing or picking up heavy objects for at least four to five hours after donating blood. If you have sports practice or a game on the day of the blood drive, we recommend you do not practice or play or if you are required to practice or play that you do not donate blood. Parental Acknowledgement Form In order to donate, this form MUST be filled out completely and printed clearly with a BLACK or BLUE ballpoint pen. Donor s Name: Donor's Last 4 SSN (if known): Donor's Date of Birth: Donor's Age: Donor's Address: CDO-013-PRD REV 11 City/State/Zip: Donor's Phone #: *Donor MUST present with a form of identification at time of donation. Donor is emancipated and has been verified by staff. I acknowledge that I have read and understand the information provided in the acknowledgement statements on the back side of this document and the blood donor requirements and I authorize the minor listed below, who is my son, daughter or someone for whom I am legally authorized to provide medical authorization, to provide a blood donation to Bonfils Blood Center. I also authorize a photo release if pictures are taken at the donation site. I understand that sensitive and personal information will be obtained from the donor prior to any donation as part of the routine donor screening process. This includes information required by the FDA pertaining to the donor s sexual history and Bonfils is required to define sexual content with explicit language that will be available on materials given to my son/daughter. Based upon this information, Bonfils will determine the suitability of the donor to donate blood. Information obtained from the donation is confidential and will not be released to third parties without the donor s consent or as otherwise required by law. I understand that I may be informed of my child's test results should Bonfils be unable to reach my child. Our blood center participates in research to improve blood safety. We may use your son/daughter s donor history information and a sample of your son/daughter s blood, in a confidential manner, for blood safety research, as described in the accompanying research information document(s). We are required to get parental consent for both 16- and 17- year old donors for this research. For more information about this research or blood donation, go to bonfils.org/reading. IN SIGNING THIS FORM, I ACKNOWLEDGE THAT MY SON/DAUGHTER IS 16 OR 17 YEARS OLD. Minor s Full Legal Name: Parent/Guardian s Name: Parent/Guardian s Signature: Phone # to call during minor s donation: Relationship to Donor: Date: PG 1 OF 2 Please call Bonfils Donor Relations department at or , opt. 1, if you have questions about your minor s donation.

3 ATTENTION MINOR AND PARENT/GUARDIAN: Please Read All Information on Front AND Back then Complete and Sign Form Below are the consent statements your son/daughter will be asked to read and sign before they donate. By signing the form on the front, you are consenting for your 16 or 17-year-old to make a voluntary blood donation. This signed form is the only verification that will be accepted - we cannot accept phone verifications. WHOLE BLOOD/PHLEBOTOMY ACKNOWLEDGEMENT Phlebotomy is the process of withdrawing blood from a vein. I am voluntarily consenting to the phlebotomy procedure for the donation of blood and have had the chance to refuse the phlebotomy procedure. Furthermore, I certify that I have answered truthfully all of the questions addressed to me regarding my present and prior illnesses, symptoms and physical conditions. I have read and truthfully answered the questions set forth in the donor questionnaire. I understand that by not disclosing all of the information set forth in the donor questionnaire, I could put myself at risk for complications or place others at risk of a transfusion transmitted disease as a result of this donation. In giving consent to Bonfils Blood Center to perform phlebotomy, I acknowledge that the procedure of phlebotomy has been explained to me and that I have had the opportunity to discuss the risks associated with phlebotomy and ask any and all questions. I understand that my blood will be TESTED for HIV, AIDS, hepatitis and other diseases. If these tests indicate that I should no longer donate blood or plasma because of a risk of transmitting disease, my name will be entered in a list of permanently deferred donors. I understand that I will be notified of an abnormal test result, which will be reported to authorities as required by law. Some tests may be unlicensed or used for research purposes. I understand that I SHOULD NOT DONATE blood if I am at risk for HIV/AIDS or hepatitis (refer to Making Your Blood Donation Safe ). If I consider myself to be a person at risk for spreading the virus known to cause AIDS, or other infectious diseases, I agree not to donate blood or other blood products for transfusion to another person or for further manufacture. I further understand that there are known COMPLICATIONS associated with donating blood. Complications can occur at the site where the needle was inserted and may extend beyond my arm and cause systemic complications throughout my body. Localized complications include: Pain Soreness Redness Bruising Swelling Bleeding vascular injury Tissue scarring Localized infection Systemic complications may include: Systemic infections Lightheadedness Fainting or passing out which may result in additional injuries if I fall or drive. I also understand that on rare occasions severe reactions to a phlebotomy procedure can have long-term or permanent effects including, but not limited to damage to nerve or muscle at or around the phlebotomy site which may result in numbness, pain or localized paralysis and the need for extended medical treatment. I understand that the blood I donate today may be used for transfusion to a patient or any other medical need Bonfils Blood Center has for its use. I also understand that my blood may be used for further manufacturing, research or investigational studies (no DNA analysis will be conducted). I give my consent to have a phlebotomist draw blood from me today. APHERESIS ACKNOWLEDGEMENT I hereby voluntarily give my permission to Bonfils Blood Center to remove blood from my body on this day by an automated procedure called apheresis. Apheresis is a procedure whereby needle(s) are placed into the vein(s) of one or both arms, whole blood is withdrawn from the donor and mixed with an anticoagulant (an agent which prevents or delays blood coagulation). The blood is then mechanically separated into various parts and a portion of that blood (red blood cells, platelets and/or plasma) is transferred to separate bags and saved. The remainder of the blood is returned to the donor (myself). This procedure may take between one and two hours to perform, during which time I will be connected to the machine and unable to get up and move around freely. Risks of apheresis range from mild discomfort to severe reactions and include but are not limited to: Anxiety, headache, pale skin tone, excessive tiredness or general weakness Hives or other allergic reaction Numbness and/or tingling of face, lips and/or fingers or muscle tension from the citrate during return of blood Low blood pressure or convulsions due to changes in blood volume Chills, fever or feelings of warmth Shortness of breath or hyperventilation Unpleasant taste sensation, nausea or vomiting PHOTO RELEASE Additional side effects for plateletpheresis (the removal of platelets during apheresis) may include a transient decrease in platelets and loss of a small amount of lymphocytes (a type of white blood cell) along with platelets. I have been informed that the effect of this loss is unclear. Loss of red blood cells due to leakage or breakage of the plastic tubing or containers may occur and thus prevent the return of red blood cells. Since the removal of blood and the return of blood are accomplished through the use of needles and tubing, it is possible that clotting could occur in the needles or tubing and this may lead to the termination of the individual procedure. There is a possibility that the red blood cells removed during the procedure could be broken down (hemolysis) due to a malfunction of the machine; however, this is rare. Although the machine is equipped with an air detector to prevent air bubbles, there is a remote possibility of an air bubble entering the donor. The consequence of this unlikely event could be severe. These, along with technical difficulties and side effects, could cause discomfort or serious problems. I understand that I will receive no medical benefit from this procedure, that my donation is voluntary and I could alternatively not undergo apheresis. I understand that I should avoid strenuous use of my arm(s) for about four hours after the donation. I have read the above statements. The procedure and risks have been explained to me. I have been given ample opportunity to ask questions about the procedure, the risks and anything I did not understand. I have had an opportunity to refuse permission and realize I can withdraw permission at any time. I give Bonfils Blood Center permission to use my son/daughters photos or likeness in future promotional materials. CDO-013-PRD REV 11rev 18 Please call Bonfils Donor Relations department at or , opt. 1, if you have questions about your minor s donation. PG 2 OF 2

4 Donor Prescreening Questions CDO-384-PRD REV 21rev Please read the following in its entirety to help guarantee your safety and the safety of the community blood supply and to help ensure you have a positive donation experience. Bonfils recommends that prior to your donation you eat within 2 hours and hydrate for hours. If you would like something to eat or drink before your donation please help yourself to the items in the canteen area. Donors are commonly deferred for the following questions. Bonfils asks these prescreening questions so donors do not spend time answering our full questionnaire only to find they are ineligible for a common reason. Even if you answer no to all of these prescreening questions, you may be ineligible to donate based on the answers given during the full questionnaire and interview process completed just prior to the actual donation. If you answer yes to any of these questions on the day you present to donate, you will NOT be eligible to donate at that time. If you have any questions related to travel or your eligibility to donate as a whole contact Bonfils Donor Relations department at or , opt. 1 or ask a Bonfils staff member at the time of your donation. HEALTH STATUS AND AGE 1. Do you weigh less than 110 pounds or more than 350 pounds? 2. Are you 15 years or younger? 3. Are you ill or not feeling well today? 4. Have you ever been diagnosed with lymphoma and/or leukemia? MEDICATIONS 5. Are you taking antibiotics today for an active infection? 6. Have you taken Accutane, Proscar or Propecia in the last month? 7. Have you taken Coumadin/Warfarin in the last 7 days? TRAVEL AND RESIDENCE ABROAD 8. From 1980 through 1990 were you in Belgium, Germany, the Netherlands or Holland as a member of the U.S. military, a civilian military employee or a dependent of a member of the U.S. military for 6 months or more?* 9. From 1980 through 1996 were you in Spain, Portugal, Turkey, Italy, Sicily or Greece as a member of the U.S. military, a civilian military employee or a dependent of a member of the U.S. military for 6 months or more?* 10. From 1980 to present have you spent time that adds up to 5 years or more in Europe?* 11. In the past 12 months have you spent more than 24 hours in (traveled to) any individual location outside of the U.S. or Canada?* a. If yes, did you travel to any of the countries or cities listed as a malarial risk area on the table on the back of this page? There are many ways to save lives with Bonfils. You can also help through Bonfils marrow program and volunteer opportunities. *Additionally, if you are deferred for these categories, you may still be eligible for research donations. Visit bonfils.org to learn more. PG 1 OF 2 Please call Bonfils Donor Relations department at or , opt. 1 for complete information on donor eligibility.

5 The table below is referenced in prescreening question 11a. Like the prescreening questions on this document that reference common deferrals but not all deferrals, this table includes common malarial risk areas but it is not an all-inclusive list. AFGHANISTAN AFRICA Angola Botswana Burundi Cameroon Central African Republic Chad Congo Ethiopia Gabon Gambia Ghana Ivory Coast Kenya Liberia Mozambique Niger Nigeria Rwanda Senegal Sierra Leone Somalia Sudan Tanzania Uganda Zaire Zambia Zimbabwe CAMBODIA CHINA Dali Banna Chuxiong City Dian Lake Jade Dragon Snow Mountain Jinghong Kunming Lijiang Nansha New Yuanyang Old Yunanyang Panzhihua Shangri-la Shilin Stone Forest Tiger Leaping Gorge Xinje Yunnan DOMINICAN REPUBLIC Any area outside Santiago or Santo Domingo HAITI HONDURAS Any area outside San Pedro Sula or Tegucigalpa (including the Bay Islands) INDIA INDONESIA IRAN MALAYSIA MEXICO Chihuahua City Copper Canyon El Fuerte Hidalgo del Parral Los Mochis Mazatlan Nuevo Mazatlan Nuevo Vallarta Punta Mita Sayulita PANAMA Any area east of the Panama Canal including the region of Colon SOUTH KOREA Any area north of Seoul, including the Demilitarized Zone (DMZ) VENEZUELA CDO-384-PRD REV 21ev Please call Bonfils Donor Relations department at or , opt. 1 for complete information on donor eligibility. PG 2 OF 2

6 Medical Guidelines BASIC REQUIREMENTS FOR BLOOD DONATION BD_4020 BD_001 rev 10 Must be at least 18 years of age or 16 or 17 with written parental or guardian acknowledgement. Weigh at least 110 pounds; if greater than 350 pounds, please call Bonfils Appointment Center at or , opt. 2. For your safety and to ensure a positive donation experience Bonfils recommends that prior to your donation you eat within 2 hours and hydrate for hours. If you would like something to eat or drink before your donation please help yourself to the items in the canteen area. Be in good general health. Proof of identification is required at time of donation. Examples include but are not limited to: driver s license, work badge, school ID, credit card, mail, etc. The donation interval after a whole blood donation is 56 days. Please contact Bonfils Blood Center for the specific interval for other blood product donations. You should not be under the influence of alcohol or recreational drugs at the time of donation. MEDICATIONS Donors should not discontinue taking medications prescribed or recommended by their physicians in order to be eligible to donate. Are you being treated with the following types of medication... Have you taken... which is also called... in the last Feldene piroxicam 2 days Anti-platelet agents Effient prasugrel (usually taken to prevent Brilinta ticagrelor 7 days stroke or heart Plavix clopidogrel attack) Ticlid ticlopidine 14 days Zontivity vorapaxar Xeralto rivaroxaban Fragmin dalteparin Lovenox enoxaparin 2 days Pradaxa dabigatran Anticoagulants or Eliquis abixaban blood thinners (usually to prevent blood Savaysa edoxaban clots in the leg and Coumadin lungs and to prevent Warfilone warfarin stokes) Jantoven Heparin, low 7 days molecular heparin weight heparin Arixta fondaparinux Acne treatment Accutane Amnesteem Absorica Claravis isotretinoin Myorisan 1 month Sotret Zenatane Hair loss remedy Propecia finasteride Proscar finasteride Prostate Symptoms Avodart Jalyn dutasteride 6 months Basal cell skin cancer Erivedge vismodegib 7 months Relapsing multiple sclerosis Aubagio Teriflunomide 2 years Psoriasis Soriatane acitretin 3 years Tegison etretinate Ever Hepatitis exposure Hepatitis B Immune Globulin HBIG 12 months HEALTH CONDITIONS Ambulatory Aid: For their own safety, donors using any type of temporary ambulatory aids including crutches, canes or other walking aids for a recent injury cannot donate until no longer requiring this assistance. Breastfeeding: Female donors that are breastfeeding are eligible to donate. Cancer: Donor is eligible with a history of basal cell or squamous cell skin cancer or carcinoma in situ. Lymphoma and leukemia are permanent deferrals. All other types of cancer will be assessed at time of donation, but 12 months must have passed since the last treatment and donor must be considered cancer free at time of donation. Colds: Donors are not eligible if they are not feeling well and healthy the day of donation. Diabetes: Donors with diabetes (type I or II) are eligible to donate. Diabetics who ever used bovine insulin manufactured in the United Kingdom are deferred. Heart Disease: Donors with a history of heart disease or heart attacks may be eligible to donate provided six months have elapsed from the incident and approval has been obtained from donor s physician. Donors with Wolff- Parkinson-White syndrome, hypertrophic cardiomyopathy and implanted/internal defibrillators are permanently ineligible. Hemochromatosis/Polycythemia: Donors diagnosed with hereditary hemochromatosis or polycythemia are asked to contact Bonfils Donor Relations. Hepatitis: Donors with a history of hepatitis B or C should refrain from donating. High Blood Pressure: Donors with high blood pressure are eligible to donate if their blood pressure is within an acceptable range when taken on the day of donation, regardless of medication. Malaria: Donor is eligible if symptom free for three years. Pregnant: Donors who are pregnant or have been pregnant in the last 6 weeks are not eligible to donate. Transfusion/Transplants: Donor is deferred for 12 months following a transplant or transfusion of blood or of blood products. PG 1 OF 2 Please call Bonfils Donor Relations department at or , opt. 1 for complete information on donor eligibility.

7 VACCINATIONS/IMMUNIZATION Vaccination/Immunization Antitoxins/animal serum injections Measles (rubeola) Mumps Polio Salk (oral vaccine) Typhoid (oral) Yellow fever German measles (rubella) BCG (Bacille Calmette-Guerin) for tuberculosis (TB) disease Hepatitis B (Recombivax, Energix-B, Heptavax) MMR (measles/mumps/rubella) Varicella zoster (chicken pox, Varivax) Shingles (Zostavax) Do Not Donate for 2 weeks 1 month (30 days) HIV/AIDS Individuals who have had a positive test for HIV/ AIDS or who are at risk for contracting HIV/AIDS are permanently deferred from donating blood. Risk factors include: Use of needles to take drugs, steroids or anything not prescribed by your doctor Taking money or drugs for sex The following risk factors represent a 12-month deferral for the donor from the date of occurrence: Male to male sexual contact in the past 12 months Intimate/sexual contact with any person in the above categories Accidental contact with another person s blood/ body fluid or an accidental needle stick Incarceration for more than 72 consecutive hours EUROPEAN TRAVEL/RESIDENCY CRITERIA CJD Variant Creutzfeldt-Jakob Disease (human form of mad cow disease). Total cumulative time spent in the United Kingdom (see list below) adding up to 3 months or more from indefinitely defers a donor from community donation. However, these donors may be eligible for research donations. Total cumulative time spent in the European Countries listed below of 5 years or more is cause for indefinite deferral from community donation, but does not defer the donor from research donations. COUNTRIES IN UNITED KINGDOM: Channel Islands England Falkland Islands EUROPEAN COUNTRIES: Albania Austria Belgium Bosnia-Herzegovina Bulgaria Channel Islands Croatia Czech Republic Denmark England Falkland Islands Finland France* Germany Gibraltar Isle of Man Northern Ireland Gibraltar Greece Hungary Isle of Man Kosovo Northern Ireland Republic of Ireland Italy (Sicily) Liechtenstein Luxembourg Macedonia Montenegro Netherlands (Holland) Norway * including its overseas departments (e.g., Martinique and others) ** including the Canary Islands and Spanish North African territories *** including the Azores ****formerly Federal Republic of Yugoslavia Scotland Wales Poland Portugal** Romania Scotland Serbia Slovak Republic Slovenia Spain*** Sweden Switzerland United Kingdom Yugoslavia**** Wales ACUPUNCTURE Acupuncture/Dry-needling: Donor is eligible if procedure was performed with single-use equipment. Otherwise, donor is deferred for 12 months. OTHER WAYS TO HELP You can save lives through Bonfils marrow program and volunteer opportunities. Additionally, if you are deferred for the reasons on this document, you may still be eligible for research donations. Visit bonfils.org to learn more. Please call Bonfils Donor Relations department at or , opt. 1 for complete information on donor eligibility. PG 2 OF 2

8 Zika Virus Research Information Sponsor / Study Title: Hologic, Inc. / Pre-pivotal Procleix Zika Virus Assay Testing of Donations From Donors of Whole Blood and Blood Components Protocol Number: B10383-ZIKVPS-CSP-01 Principal Investigator: Phillip Willaimson, PhD Telephone: Donor Relations: Additional Contacts: Kadi Schroeder: Please read this form carefully. Take time to ask the donor center staff as many questions about the use of your blood for research studies as you would like. The donor center staff can explain words or information that you do not understand. Reading this form and talking to the donor center staff may help you decide whether to donate or not. You are being asked to participate in a research study to evaluate a new test for detection of a mosquito-borne agent known as Zika virus. Zika is a virus that rarely causes paralytic nervous system damage, but in pregnancy, can cause loss of the baby or serious birth defects. Most people do not get sick after infection. Only one in five people will have fever, rash, joint pain, and conjunctivitis (red eyes) lasting a few days to a week. Zika is usually transmitted by the bite of an infected mosquito. It can also be transmitted by sex with an infected man, from a pregnant mother to her baby and by blood transfusion. This donor center is doing a research study to understand the effectiveness of a new test to detect the Zika virus in donated blood and prevent patient exposure. Some of this research is conducted with other institutions, such as blood bank organizations, academic centers and biomedical companies. Any remainder of your donation may be stored up to 3 years after the completion of the study and used for further research related to the Zika virus. Samples linked to your identifying information will be tested for ZIKA virus. If your test results suggest that you may be infected, this donation center will attempt to contact you to notify you and explain the significance of the results. The donation center will discuss the potential risk for sexual transmission of Zika Virus, and potential harm to the fetus during pregnancy. You will be notified in person, by phone, or by letter. If your test results suggest that you may be infected, you should discuss these results with your primary care physician. You may also visit the Centers for Disease Control and Prevention (CDC) website at for additional information regarding Zika virus. If the results suggest that you may have a Zika virus infection, you will be invited to participate in a voluntary follow-up study involving additional blood samples. Should you choose to participate, an additional informed consent process will be required. Your participation in this research study is entirely voluntary. You will not be paid for your participation in this study. Your participation will not require any additional procedures or time beyond the normal donation process. The risk of having your donation tested with the study test is not any greater than having your donation tested for other infectious diseases, although a positive result may alarm you. There is a very low chance that your blood sample may give a false positive result. If the test is positive, the blood that you donate will not be used for transfusion. There will be no costs or payments to you for your participation in this study. Although you may not receive a direct benefit from this study, the results may allow for better test systems to become available to protect the blood supply. CDO-VC-43 rev. 1 Page 1 of 2

9 Zika Virus Research Information The results of all testing on your donation during this study are confidential, except when reportable by law to public health authorities, and to authorized blood center personnel, the U.S. Food and Drug Administration (FDA), and Hologic, Inc. Your age, gender, general geographic location, and test results may be used to evaluate important information about Zika virus, but this information is combined with information about other donors and not identified with you. You may refuse to participate by notifying the blood collection staff that you will not be donating blood or blood components today. If you decline testing we will be unable to use your whole blood or red blood cells, however, we will inform you whether you may donate plasma or platelets. If you decide not to participate at this time, your decision will not change your future relationship with the blood center and there is no penalty to you. If you decide not to participate after your donation is taken, call the Principal Investigator at the number(s) above. An Independent Review Board (IRB) is a group of people who review research studies to protect the rights and welfare of research participants. If you have questions or complaints about your rights as a study participant contact the Chesapeake IRB: By mail: Study Subject Adviser Chesapeake IRB 6940 Columbia Gateway Drive, Suite 110 Columbia, MD or call toll free: or by adviser@chesapeakeirb.com Please reference the following number when contacting the Study Subject Adviser: Pro If you have scientific questions or questions about your participation in these studies, you may contact our Donor Counseling Service at , Monday Friday 8am-5pm. By signing your Blood Donation Record, you are giving consent to allow us to use a portion of your blood donation and associated information for research purposes related to Zika virus. Although you feel well and healthy at the time of your donation, please call us immediately at the phone number beside our donor center s name below if you develop any of the following symptoms within 14 days of your blood donation: Fever Rash Muscle or joint pain Eye pain or redness Headache By notifying us as soon as possible after developing any of these symptoms you may prevent the blood you donated today from being transfused and possibly infecting a patient. NOTE: If you recall being in an area where Zika is actively transmitted in the past 4 weeks, please call us. Although you are feeling well, you could be infected with Zika. Bonfils Blood Center ( CDO-VC-43 rev. 1 Page 2 of 2