Yes

No

 

Are you

 

 

1.       Feeling healthy and well today?

q

q

2.       Currently taking an antibiotic?

q

q

3.       Currently taking any other medication for an infection?

q

q

 

 

 

Please read the Medication Deferral List.

 

 

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

q

q

 

 

 

5.       Have you read the educational materials and had your questions answered?

q

q

 

 

 

In the past 48 hours

 

 

6.       Have you taken aspirin or anything that has aspirin in it?

q

q

 

 

 

In the past 6 weeks

 

 

7.       Female donors: Have you been pregnant or are you pregnant now? (Males: check “I am male.”)

q

q

q I am male

 

 

 

 

In the past 8 weeks have you

 

 

8.       Donated blood, platelets or plasma?

q

q

9.       Had any vaccinations or other shots?

q

q

10.   Had close contact with the smallpox vaccination site of someone else?

q

q

 

 

 

In the past 16 weeks

 

 

11.   Have you donated a double unit of red cells using an apheresis machine?

q

q

 

 

 

In the past 12 months have you

 

 

12.   Had a blood transfusion?

q

q

13.   Had a transplant such as organ, tissue, or bone marrow?

q

q

14.   Had a graft such as bone or skin?

q

q

15.   Come into contact with someone else’s blood?

q

q

16.   Had an accidental needle-stick?

q

q

17.   Had sexual contact with anyone who has HIV/AIDS or has had a positive test for the HIV/AIDS virus?

q

q

18.   Had sexual contact with a prostitute or anyone else who takes money or drugs or other payment for sex?

q

q

19.   Had sexual contact with anyone who has ever used needles to take drugs or steroids, or anything not prescribed by their doctor?

q

q

20.   Had sexual contact with anyone who has hemophilia or has used clotting factor concentrates?

q

q

21.   Female donors: Had sexual contact with a male who has ever had sexual contact with another male?  (Males: check “I am male.”)

q

q

q I am male

 

Yes

No

 

22.   Had sexual contact with a person who has hepatitis?

q

q

23.   Lived with a person who has hepatitis?

q

q

24.   Had a tattoo?

q

q

25.   Had ear or body piercing?

q

q

26.   Had or been treated for syphilis or gonorrhea?

q

q

27.   Been in juvenile detention, lockup, jail, or prison for more than 72 hours?

q

q

 

 

 

In the past three years have you

 

 

28.   Been outside the United States or Canada?

q

q

 

 

 

From 1980 through 1996,

 

 

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

q

q

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?

q

q

 

 

 

From 1980 to the present, did you

 

 

31.   Spend time that adds up to five (5) years or more in Europe? (Review

list of countries in Europe.)

q

q

32.   Receive a blood transfusion in the United Kingdom ? (Review list of countries in the UK.)

q

q

 

 

 

From 1977 to the present, have you

 

 

33.   Received money, drugs, or other payment for sex?

q

q

34.   Male donors: had sexual contact with another male, even once? 

(Females: check “I am female.”)

q

q

q I am female

 

 

 

 

Have you EVER

 

 

35.   Had a positive test for the HIV/AIDS virus?

q

q

36.   Used needles to take drugs, steroids, or anything not prescribed by your doctor?

q

q

37.   Used clotting factor concentrates?

q

q

38.   Had hepatitis?

q

q

39.   Had malaria?

q

q

40.   Had Chagas’ disease?

q

q

41.   Had babesiosis?

q

q

42.   Received a dura mater (or brain covering) graft?

q

q

43.   Had any type of cancer, including leukemia?

q

q

44.   Had any problems with your heart or lungs?

q

q

45.   Had a bleeding condition or a blood disease?

q

q

46.   Had sexual contact with anyone who was born in or lived in Africa?

q

q

47.   Been in Africa?

q

q

48.   Have any of your relatives had Creutzfeldt-Jakob disease?

q

q