HONG KONG RED CROSS BLOOD TRANSFUSION SERVICE BLOOD DONATION REGISTRATION FORM
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1 I Bleed no. HONG KONG RED CROSS BLOOD TRANSFUSION SERVICE <W BLOOD DONATION REGISTRATION FORM PART A : PRE-DONATION INFORMATION Thank you for giving blood today. Your donation could save and change the life of someone. To safeguard your safety as a blood donor and ensure blood safety, it is vital that we review every potential donor's suitability to donate on each visit through rigorous health screening. If you are uncertain about any questions on this form, please talk with any of our health care staff on duty. The Hong Kong Red Cross Blood Transfusion Service is committed to the provision of safe blood and blood products to those who need them. Your blood donation will be stringently screened for infectious diseases before it is processed into blood products for patient use. Most donations of blood will be used to treat patients in Hong Kong. However, a small proportion of donations will need to be used for quality assurance testing or in academic or medical research. In addition, genuine excess blood may be made available to patients outside of Hong Kong in exceptional circumstances to avoid wastage. Some blood donors may occasionally suffer bruising, pain or infection around the needle puncture site, or even experience dizziness or faint after donation. These problems are usually mild and short-lasting. However, we advise blood donors who suffer such effects to seek medical consultation nearby, if they are worried. Alternatively, they can contact us directly for enqumes. To minimise the occurrence of such adverse conditions, we sincerely request blood donors to follow the instruction in our "Post-Donation Advice". If your blood test results are positive, we shall inform you with your personal information provided on the Blood Donation Registration Form (including name, correspondence address, telephone number and ). Furthermore, we would like to use your personal data from time to time to keep you informed of our activity news and blood donation promotions. Should you have any queries, please feel free to ask our health care staff on duty. Safe Blood Save Lives DO NOT give blood if you suspect your blood carries a potential risk of transmitting an infection to a patient who may receive your blood. DO NOT give blood for the purpose of blood testing. It is because an infection may not be detected through blood tests at its onset. For free AIDS testing, please call WIBCS2/Fl _J6
2 PART B : HEALTH ENQUIRY Please indicate whether you have the following condition(s) by putting an./" in the correct box. Please be assured that a "YES" answer to any of the questions will not necessari!_-v result in deferment of blood donation. You will be asked to speak IN CONFIDENCE to our staff who will decide ifyou can donate. The information you disclose will be kept in strict confidence. Thank you. TODAY / NOW YES NO Staff Use 1. Are you feeling well enough to give blood today? 2. Are you currently under a doctor's treatment, taking any medication or awaiting test result? 3. For female donors: Are you pregnant? Have you given birth I had an abortion in the last 12 months? 4. Are you about to undertake any hazardous sports, e.g. rock dumbing, diving or flying today? 5. Will you be driving a heavy vehicle or working at hazardous depths or heights today? e.g. fireman, train I lorry driver, scaffolding worker IN THE PAST 3 DAYS 6. Have you had any dental procedure, open wounds or skin lesions? 7. Have you taken aspirin or any medication containing aspirin? IN THE PAST 4 WEEKS 8. Have you had contact with an infectious disease e.g. chickenpox, rubella, tuberculosis? 9. Have you had any vaccinations e.g. Hepatitis A, Hepatitis B or tetanus? 1. Have you had diarrhoea? IN THE PAST 12 MONTHS 11. Have you had tattoo, acupuncture, ear I body piercing or been accidentally stuck with a used needle? Have you had accidental exposure to blood I blood contaminated instruments? 12. Have you been given Hepatitis B Immune Globulin? 13. Have you had rabies shots? 14. Have you undergone or received surgery (including endoscopic examination, treatment involving the use of catheters)? blood transfusion? WJ8CS2IFI_ I6
3 YOUR HEALTH YES NO Staff Use 15. Have you ever registered or donated under another name? 16. Have you ever been permanently deferred as a blood donor or been advised not to donate blood? 17. Have you ever received clotting factor concentrates? growth hormone of human origin, other pituitary hormones? brain tissue grafts? organ or tissue transplant? any treatment for infertility? Have any of your family members suffered from Creutzfeldt-Jakob Disease (CJD)? 18. Have you traveled outside Hong Kong in the past twelve months? When Where : Are you residing in Hong Kong less than three years? Last country of residence: 19. Have you ever had any serious illness? Please tick r.i J any of the followings that applies to you: o heart disease (e.g. ischaemic heart disease, hypertension), o respiratory disease (e.g. asthma), o gastrointestinal disease, o blood disease (e.g. bleeding problem), o cancer, o endocrine or metabolic disease (e.g. diabetes), o neurological disease (e.g. epilepsy), o mental disorder, o urogenital disease (e.g. kidney or bladder disease), o autoimmune disease (e.g. SLE, Rheumatoid arthritis), o other Have you had loss of consciousness I convulsions? Have you had a drug allergy? 2. Have you ever suffered from an infectious disease such as malaria, venereal disease, tuberculosis or glandular fever? 21. Have you ever been informed of G6PD deficiency? 22. Have you been a carrier of hepatitis B virus? hepatitis C virus? WIBCS2/F1_16
4 LIFE STYLE YES NO Staff Use 23. Do you or your sexual partner(s) have any reason to believe that you have been infected with HIV, the virus that cause AIDS? Have you had sexual activity with anyone whom you think might be HIV positive? Have you ever been given money for sex? Have you a history of drug abuse or ever injected yourself with drugs? In the last 12 months, have you had sexual activity with a bisexual male? a male or female sex worker? anyone who has a history of drug abuse or has injected himself I herself with drugs? anyone who has received clotting factor concentrates? ( For male donors ) Have you ever had male-to-male sexual activity? 24. Have you spent a total of three or more months in the UK between 1 January 198 and 31 December 1996? Have you spent a total of five or more years in France between 1 January 198 and the present? Have you spent a total of five or more years in Europe between 1 January 198 and the present? Have you received blood transfusion in the UK or France between 1 January 198 and the present? Have you worked or lived for a total of six or more months at US Military bases in Europe between 1 January 198 and 31 December 1996? 25. Have you received bovine insulin injection since 1 January 198? ADDITIONAL QUESTIONS 26. Have you been to North America recently? 27. In the past 2 weeks, did you have symptoms of flu, fever, headache, eye pain, muscle/joint pain, vomiting, enlarged lymph node or skin rash? 28. Do you have any history of confirmed Dengue fever? 29. Do you have any history of close contact with patient confirmed or suspected SARS? 3. Do you have any history of confirmed or suspected SARS? - - Declaration: I confirm that I have read, understood and agreed with ' Part A : Pre-donation Information' and the staff on duty has answered all my queries. I confirm that all information which I have provided in 'Part B : Health Enquiry' is correct. I also consent to have my blood tested for such infectious diseases (including HTV) as the Hong Kong Red Cross Blood Transfusion Service may consider necessary from time to time. I understand that I will be informed by the Hong Kong Red Cross Blood Transfusion Service if my blood is tested positive for any infectious disease. Verified donor's signature by Donor Signature: Date: _ Staff Signature: (Please sign in front of screening nurse) WIBCS2/FI_I6
5 PART C: PERSONAL INFORMATION (Corresponds to Personal Identity Document) ( Photocopy of form is not accepted) Bleed no. Name HKIDNo. Surname Other Name (Name in Chinese if applicable) Date of Birth (DD) (MM) (YY) ----~~~----~~----~~~ Sex Weight Blood donated in HK Corresponding Address (Please provide accurate address for future correspondence) (Kg) Yes D H.K. Height (em) Blood Group (ifknown) Donor No NoD Last Donation Date KLN. N.T. Daytime Tel. No. Mobile Tel. No. Night time Tel. No. Affix Donor Label Address I object to the aforesaid use of my personal data for blood donation related information and promotional activities and/or events held by HKRCBTS For Q(fice U.<>e Onlv (Please.,/where appropriate) Donor Examination Drive ID: Blood Pack Lot No Hb Test Performed By BP mmhg P /min. Hb/Counter Reading I g/dl Hb/Counter Eq. No EIHMC: EIAUA: A pheresi... Plasma only Time Hb tested ;..._..:._~ - ;..._..:._...;! hr.m in Plasma & Platelet Platelet only Blood Unit Weigher Equipment No : =E=IM:.;.:.: IX:..:......:.IE=IB::.AL:.=:... :IE.:::::.I.::::C::.P..:.. P Hand Held Sealer Equipment No : No ofbn Label... Used I Destroved : EITCS ~~~ I Blood Flow Blood Pack (WB Donationl Volume (;_ollectf:_d Remarks Require new card Aspirin Stain/Mark Small Vein Autologous Donation Directed Donation YesO NoD Ferrous Sulphate 3mg/tablet (14 tablets for 14 days) One tablet daily Start Time... lhr.min Quadruple 45 Over Collection End Time...!hr. min Quadruple 35 Low Volume Unit Duration mtn Single Inadequate Collection Fail mls collected Dispensed by Staff Health Screened By : \Staff Access for Venepuncture: Special Message : Accepted for Donation and Venepuncture By: Venepuncture Completed By: Deferral Hold Remark : Deferral Duration : Lt / Rt (I'') Lt / Rt (2"") Staff: I Staff ( I" ) (2"") I Comment: Staff WIBCS2IFJ_/6
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