REDVIVE BLOOD DONATION SURVEY FORM

The following survey form is designed to understand whether or not people are open to the idea of
donating blood for a good cause.

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Gender: o Male o Female o Other
Blood Group: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Are you under 16 years old? : o Yes o No
Age (in years): o 18-33 o 33-48 o 48 and above
Do you weigh 50 kg or less? : o Yes o No
Do you suffer from any disease (eg: Hypertension, Diabetes, etc.)
o Yes (Please specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _) o No
Have you ever donated blood? : o Yes o No
(If yes, then go to Section A, otherwise Section B)

Section A
1. How many times have you donated blood?
o 1 time
o 2-4 times
o 4-10 times
o Regular Donor
If Regular donor, how often in a year? : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

2. Where do you generally prefer to donate?

o With Blood Bank
o With Blood Camp
o With Blood Mobile vane

3. Which Blood Bank do you generally prefer to donate? :

o________________________ o I can’t say

4. What motivates you to donate blood?

o Emergency requirement for friend or relative
o When motivated by Blood Bank Staff
o To stay physically fit
o Urge to help others
o Motivated by any fellow blood donor
o Other (Please specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _)
 Section B

1. What are the reasons for not donating Blood?

o Fear of prick
o Not physically fit
o Lack of motivation
o Fear of some infection/disease
o Other (Please specify: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _)

2. Do you think Blood Donation is necessary?

o Yes o No o I can’t say

3. Do you engage in any Charity / Social work / Philanthropic Activity?

o Yes o No

4. Would you want to donate blood in the future?

o Yes o No

If yes, kindly provide Contact Number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Email ID: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(Contact Information will remain confidential)

Thank you for your valuable contribution. Have a good day!