Version：2013 edition
Number：DS066-2-130801
[blood donation registration form]
Blood donation registration form
（Write in pen please）
Organization type：
Donation site：
Blood type（queried）：
Date:
Verifier：
Personal Information
Name
Identification
Gender
Date of birth
Nationality
□Passport □Hong Kong-Macau pass □Mainland travel permit for Taiwan residents
□Others
Identification
Number
Occupation
□medical workers □teacher □student □others
Residence
Status
□Lived in China for more than 6 months
□Lived in China for less than 6 months
Mobile No.
Home Tel.
Email
address
Contact
address
Postcode
First time
donating?
□Yes □No
Adverse donor
reaction：
□Yes
Type of
donation
Whole blood
□400ml
□200ml
Blood component
□No
Last donation date：
_____(DD)_______(MM)______(YY)
Platelets：□double unit □single unit
□others：
Would you like to donate blood in an emergency?
□Yes
□No
□have joined
Would you like to donate blood components?
□Yes
□No
□have joined
Would you like to donate hematopoietic stem cells?
□Yes
□No
□have joined
Would you like to become a regular blood donor?
□Yes
□No
□have joined
Private willing
Please select the method to notify you about
your blood test results
1
□Unnecessary
□If you need, choose one of the following methods
□text message □E-mail □mail
□online inquiry（ask our staff for instructions and password）
Version：2013 edition
[blood donation registration form]
Number：DS066-2-130801
Blood donor notification
Thank you for giving blood today. Your donation could potentially save the life of someone in
need of blood or help them through an operation. Your complete honesty in answering all
questions is very important for the safety of patients who receive your blood. Please carefully
read the educational materials and the following information before donating! Even if you answer
“Yes” to any of the medical history questions does not necessarily make you ineligible to donate
blood. If you have any questions, please ask our blood center staffs .All information you provide
will remain confidential. Thank you for your understanding and support.
1. It is altruistic when you donate blood. Your blood will be used to help patients who need blood
transfusion. Please do not give blood for the purpose of blood testing. For free AIDS testing and
consultation in China, please contact the local Centers for Disease Control and Prevention
(Telephone number can be reached on National Health Hotline: 12320)
2. Unsafe blood will endanger the lives and health of patients. A person who has high risk factors
such as intravenous drug users, MSM (men who have sex with men) or blood transmitted
diseases (AIDS, hepatitis B and C, syphilis) should not donate blood.
3. It is dangerous for the recipient if the donors donate unsafe blood. If you donate blood while
you think you may be at high risk for blood transmitted disease, which caused the spread of
infectious diseases, you will be charged with legal responsibility according to “Law of the PRC
on the Prevention and Treatment of Infectious Diseases (No. 77)” and “Local regulation of AIDS
Prevention (No. 38 and No.62)”.
4. The donors should show valid identification before donating blood as required by “Measures
for the Administration of Blood Stations”, those who use someone else's identity to donate blood
shall bear the corresponding legal responsibility.
5. Please call us as soon as possible if you believe your blood is not safe for transfusion. (Contact
phone: 021-62758257). We will dispose your blood. Information regarding this will remain
confidential.
6. The blood donation process includes reading educational materials and notification, health
enquiry, physical examination and preliminary blood screening, blood collection and rest after
blood donation. Donors have opportunity to ask questions and give or refuse consent for donation.
The donation process is safe as only disposable sterile materials are used during blood collection
to safeguard the safety of donor and patients. Some blood donors may occasionally have mild
reaction such bruising, pain, bleeding or infection around the needle puncture site, or experience
dizziness or fainting after donation mainly because of lack of sleep, fasting before blood donation,
feeling tense and incorrect puncture site press. To minimize the occurrence of such adverse
reactions, we sincerely request blood donors to follow the guidance in our “blood donor
educational materials”. Blood donors may also contact us directly for any other inquiries.
7. The donors will be given health enquiry and physical examination before blood donation
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Version：2013 edition
[blood donation registration form]
Number：DS066-2-130801
according to “Blood Donation Law of the PRC”. You should truthfully fill out the registration
form. The person who provides false information will be charged with responsibility if adverse
consequences were caused by the donated blood. If the questions are related to your privacy or
make you unhappy, we apologize and ask for your forgiveness.
8. The blood will be tested for blood transmittable diseases in accordance with the provisions of
the state as unsafe blood could spread disease, which qualified is used in clinic while disqualified
is treated according to national regulation. If you have any positive test result, it just means that
your blood does not meet with the requirements of national standards of blood donation. Blood
test results should not be used as a basis of disease diagnosis. Testing procedures are not perfect
and there are circumstances in which infectious disease tests are not detected by the current
detection techniques.
9. The donor information and test results will be reported to the local Center for Disease Control
and Prevention necessary required by Law of the People’s Republic of China on the Prevention
and Treatment of Infectious Diseases.
10. Most donated blood will be used to treat patients. However, a small proportion of donation
will be used for quality assurance testing or medical research, including statistics, summary and
analysis for the purpose of blood safety.
3
Version：2013 edition
[blood donation registration form]
Number：DS066-2-130801
History Questionnaire
Please indicate whether you have the following conditions by putting an “√” in the correct box.
1.Today/Now Are you
1.1 Feeling unhealthy for blood donation today?
1.2 About to undertake any hazardous sports such as rock climbing, diving, flying, driving a heavy
vehicle or working at hazardous depths or heights after blood donation today?( e.g. aviator, fireman
or scaffolding worker)
1.3 Have severe limb disability, functional impairment or redness and swelling of joints?
Yes
No
□
□
□
□
□
□
2. In the past three days have you ever had any dental procedure (including toothwash)?
□
□
3.In the past 2 weeks have you
3.1 Had tooth extraction?
3.2 Donated platelets?
□
□
4. In the past 4 weeks have you had any injection of tetanus antitoxin or rabies antiserum?
□
□
5. In the past 3 months have you undergone surgery such as appendectomy, herniorrhaphy,
tonsillectomy or eye surgery?
□
□
6. In the past 6 months have you donated whole blood?
□
□
7. In the past 12 months have you
7.1 Had a tattoo, ear piercing, accidental exposure to contaminated blood/blood instruments?
7.2 Been given Hepatitis B Immune Globulin or rabies vaccine after animal bite?
7.3 Undergone major operations (including benign gynecologic and body surface tumor etc.),
endoscopic examination or treatment by catheters etc.?
7.4 Received blood transfusion or clotting factor concentrates?
7.5 Had sexual contact with: Anyone who has HIV/AIDS or has a positive test for the HIV/AIDS virus;
Anyone who has a history of drug abuse or has injected himself/herself with drugs; A bisexual male;
Anyone who has a positive HBsAg test or hepatitis; Anyone who has a history of syphilis or gonorrhea?
7.6 Been in juvenile detention, lockup, jail, or prison for more than 72 hours?
8. Have you had acute infection of respiratory tract, urinary tract, digestive tract or skin? Have you had
acute eye diseases? Have you had acute pneumonia, pyelonephritis or acute rheumatic fever?
9. Have you had bacillary dysentery, toxoplasmosis, hepatitis A, typhoid fever, bang’s disease, Q fever
and malaria and other infectious diseases?
If you answered “Yes” in question 8 or 9, please clearly indicate: name of disease:
, date of
diagnosis
, date of recovery
.
10. Have you had contact with anyone who has infectious diseases such as cholera, typhoid fever,
hepatitis, tuberculosis, chickenpox, measles, dysentery, malaria, toxoplasmosis or other infectious
diseases?
If you have, please clearly indicate: name of disease
,the last date of
contact
11. Have you ever had any serious illness? Have you ever had parasitic diseases or endemic diseases?
Have you had tumor?
If you have, please clearly indicate: name of disease
,
date of diagnosis
□
□
□
□
□
□
□
□
□
□
□
□
□
□
12.Have you ever
12.1 Been advised not to donate blood permanently? had a positive HBsAg test?
12.2 Had the following infectious diseases?
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Version：2013 edition
Number：DS066-2-130801
[blood donation registration form]
1) Viral hepatitis or virus infection or positive hepatitis B, C test
2) Syphilis or positive Treponema pallidum test
3) AIDS or positive HIV test
4) Gonorrhea, Condylomata Acuminate
5) Lepriasis
6) HTLV infection
12.3 Your health
1) Have you or any of your relatives had Creutzfeldt-Jakob Disease(CJD)? Have you ever received
cornea and dura mater of brain grafts, human growth hormone from patients suffered from CJD?
2) Have you had repeated syncope, spasm, convulsion or unconsciousness?
3) Have you ever had repeated allergic reaction or drug allergy attack?
4) Have you ever suffered from pulmonary or extra-pulmonary tuberculosis?
5) Have you ever had silicosis or toxic and radioactive occupational diseases?
6) Have you ever had an organ or tissue transplant?
7) Have you ever had the important organ resection operation such as liver, stomach, 8) kidney, spleen
or lung etc.?
9) Have you ever used bovine insulin made in Britain?
10) Have you used corticoid, immunosuppressant, sedative-hypnotics on a long-term basis? Have you
had alcohol or drug dependence?
□
□
13.Your life style
13.1 Have you a history of drug abuse or ever injected yourself with drugs?
13.2 Have you ever taken money or paid for sex?
13.3 (For male donors) Had sexual contact with another male?
13.5 Can you think of other situations which can make you ineligible to donate blood?
□
□
14.Medication compliance：Have you ever taken any medicine such as antibiotics, anticoagulants,
antipyretic analgesics, medicines for prostatic hyperplasia and acne?
□
□
If you have, please indicate: name of medicine
, medication date :
, the last date of use:
□
□
□
□
17. Are you allergic to iodine?
□
□
18. (For female donors) Have a menstrual cycle three days before or after? Are you pregnant? Have you
given birth or breast-feeding in the past 12 months or had an abortion in the past 6 months?
□
□
15. Vaccination: In the past 2 months, have you had any vaccinations?
If you have, please indicate: name of vaccine:
, inoculation date:
16. Travel: Have you traveled or lived in blood transfusion related epidemic countries or regions?
If you have, please indicate: country(region):
,date:
Staff Signature:
, retention time:
Date:
(DD)
(MM)
(YY)
Declaration
I confirm that I have read, understood and agreed with “Blood Donation materials and
notification”. I understand the blood donation process and the knowledge of blood transmitted
diseases. I confirmed that all information which I have provided in “Blood donation registration
form” is correct. I am willing to bear all the consequences of providing false information. I also
consent to have my blood tested or anonymously used in the research for safe blood transfusion. I
understood that my donated blood test is just for the purpose of safe blood transfusion and not for
disease diagnosis or other purposes.
Blood Donor Signature:
Date:
(DD)
(MM)
(YY)
5
Version：2013 edition
Number：DS066-2-130801
[blood donation registration form]
Records before blood donation
Physical
examination
Xanthochromia of skin and sclera
□Yes □No
Weight
kg
□Normal □Abnormal
Temperature
Height
cm
Conclusion of □Qualified
examination
□Unqualified
Pulse
bpm
mmHg
Staff signature：
Remarks
Test
①ALT：
before donation
②Hemoglobin（specific gravity）：□Eligible
□Whole blood
BP
℃
U/L
□Ineligible
□Positive
③HBsAg：□Negative
④Primarily screening of ABO blood type ABO：
① Primarily screening of ABO blood
type ABO：
②ALT：
Donors who donated from last
donation for one year and new ones
U/L
③HBsAg：□Negative □Positive
need to be detected:：
④Hemoglobin：
①HIV： □Positive □Negative
□Apheresis
g/L
⑤HCT：
②HCV：□Positive □Negative
%
⑥Platelet count of before donation
：
③TP：
×109/L
⑦Chylemia: □No
Conclusion of
□Eligible □Ineligible
examination
□Yes
Remarks
□Qualified for blood donation
General comment
Staff signature：
Staff signature：
□Unqualified for blood donation
Unqualified detailed has
□deferral of blood donation （ □questionaire been notified.
□examination□primarilyscreening□Others ）
6
□Positive □Negative
Staff signature:
Donor signature:
Version：2013 edition
Number：DS066-2-130801
[blood donation registration form]
Blood collection records
Arms inspection before blood collection: skin wound or puncture marks on
the venipuncture site of both arms：□Yes □No
Whole blood bag before collection：
□have checked package intact
Sequence code of blood
donation:
Batch number：
Whole blood
Blood volume
□400 ml
□200ml
□others：
ml
Blood flow
Apheresis
□double unit
□single unit
□others：
Start time：
hr
min
End time：
hr
min
ml
Separator number：
Records of apheresis information
Supplies batch number：
Anticoagulation solution (I)batch number：
Usage volume：
ml
Sodium Chloride Injection batch number:
Usage volume：
ml
×1011
Objective volume：
Collection volume：
Handing volume：
ml
ml
Platelet counts after collection(prior estimate)：
Records of
collection
procedure
×109/L
□Smoothly
□not smoothly
□ secondary puncture □others：
Identification consistency check(blood collection bag, registration
Blood Donor signature：
Staff signature：
form, test sample, sample tube)：□ have checked
Adverse donor
Records：
reactions and
disposal
Type：□general reaction：□mild □moderate □severe；
□Yes
□No
□local reaction ： □puncture hematoma □failure puncture into artery ；
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Version：2013 edition
Number：DS066-2-130801
[blood donation registration form]
□misadventure；□others：
Symptom：
□conscious □nervous and anxious □pallor □mild sweat □dizzy □nausea □vomit
□accelerated breathing □hypopnea □pulse slow □polycardia □hematoma
□spasms
□hyperventilation □bleeding □loss of consciousness about
min
□others
Disposal：
□stop collection
□trendelenburg position
□monitor BP, pulse
□psychological counseling □provide drinks
Time of occurrence：
BP：
/
mmHg
Recovery time：
BP：
/
mmHg
Pulse：
Pulse：
b/m
b/m
Additional disposal：
Recovery condition：□Good
□Escort home
Staff signature：
8
□others：
Donor signature：
Unqualified
details(if exist)
Blood donation
certificate No.
□Referral
Verifier：
Remarks
Reviewer for the integrity of
the form: