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BLOOD DONATION APPLICATION FORM

SANGLAH GENERAL HOSPITAL-BLOOD TRANSFUSION UNIT

Thank you for enrolling to donate Blood.

Please fill in completely using capital letters

DONOR ID :

ID CARD Number :

Full Name :

Sex :

Present Address :

Phone ( home ) :

( work) :

( mobile) :

Email address :

Current Occupation : a. Student b. Government Employee, Soldier, Police

c. Company,Employee d. Monk, Priest e. Others specify……..

Date of Birth ( dd/mm/yy) :

(Age between 17- 70 ) If you are 17 years old, do you have a parent or guardian signed consent form?

≥ 60- 70 years old, Do you have a medical certificate?

When did you donate last time :

Doctor's name :
Medical Record :
Blood pressure ----- pulse : … mm/Hg----- pulse :….
Weight :…. kg
Height :….. cm
Temperature :….. oC

FOR REGISTRATION STAFF

Name :
Type of Validation : a. DONOR ID b. ID CARD c. DRIVING LICENCE

d. PASPOR

HAEMOGLOBINE TEST

Name :
Donate purpose : a. volunteer b. toward to…( recipient’s name )

Type of Donate : a. Whole Blood b. Apheresis c. Autologus

Haemoglobine : … gr/dL---- Instrument code : ----- Lot. Number/ ED :

Blood Type :
Rhesus :

FOR AFTAP STAFF

Name :
Arm : a. right b. left

Blood Bag Unit Validation : a. valid b. invalid

Scale code :
Redraw Blood Donation : a. 1 time b. 2 times

Duration of Donating : a. ≤ 12 minutes b. 12- 15 minutes c. ≥ 15 minutes

Blood Bag Unit Number :

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 For your own safety and the patient's safety who will receive your Blood, please read the questions
carefully and respond by placing a cross "X" in the relevant box.

Today

1. Are you feeling well enough to give Blood today?

2. Do you currently take antibiotics?
3. Do you currently take any other medication for an infection?

In the past 48 hours

4. Have you taken Aspirin or any medication containing Aspirin?

In the past week

5. Did you feel dizzy and fever at the same time?

In the past 6 weeks

6. For female :
1) Are you pregnant?
2) Have you given birth/ had a miscarriage in the last 6 months?
3) Have a menstruation/period?
4) Do breastfeed?

In the past 8 weeks

7. Have you donated blood, platelets or plasma?

8. Have you had any vaccinations or other shots?
9. Have you had contact with someone who had a smallpox vaccination?

In the past 16 weeks

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

In the past 12 months, have you,

11. Had a blood transfusion?

12. Had a transplant such as an organ, tissue, or bone marrow?
13. Had a graft such as bone or skin?
14. Had an accidental needle-stick?
15. Had sexual contact with anyone with HIV/AIDS or had a positive test for the HIV/AIDS virus?
16. Had sexual contact with a prostitute or anyone else who takes money or drugs or other payment
for sex?
17. Had sexual contact with anyone who has ever used needles to take drugs or steroids or anything
not prescribed by their doctor?
18. Had sexual contact with anyone with hemophilia or used clotting factor concentrates?
19. Female donors: had sexual contact with a male who has ever had sexual contact with another
male? (Males: check "I am male.”) I am male
20. Had sexual contact with a person who has hepatitis?
21. Lived with a person who has hepatitis?
22. Have you received money, drugs, or other payment for sex?
23. Had a tattoo?
24. Had ear or body piercing?
25. Have you been treated for syphilis or gonorrhea?
26. Have you been in juvenile detention, lockup, jail, or prison for more than 72 hours?
27. Used needles to take drugs, steroids, or anything not prescribed by your doctor?

In the past three years, have you,

28. Been outside Indonesia

From 1980 through 1996

29. Did you spend time that adds up to 3 months or more in the United Kingdom?

From 1980 to the present, did you,

30. Spend the time that adds up to 5 years or more in Europe?

31. Receive a blood transfusion in the United Kingdom?

From 1977 to the present,

32. Received money, drugs or other payments for sex?

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

Have you EVER,

34. Had a positive test for the HIV/AIDS virus?
35. Used needles to take drugs, steroids, or anything not prescribed by your doctor?
36. Taken any of the clotting factors concentrate on medication?
37. Had hepatitis?
38. Had malaria?
39. Had any type of cancer, including leukemia?
40. Had any problems with your heart or lungs?
41. Had a bleeding condition or blood disease?
42. Had sexual contact with anyone who was born in or lived in Africa?
43. Live in Africa?

a. Allowing Donors to donate Blood

b. Not allowing Donor to donate Blood

I hereby attest that I have answered all of the following questions truthfully. I agree to donate my
blood and declare that I was informed of the procedure. I understand the questions that have been
posed to me, and I understand that if my answers are truthful, my blood can be donated. I have
been informed and agreed that my blood will be studied and tested for Syphilis, Hepatitis B and
C, as well as HIV/AIDS, and that I will be notified if the results change and I need to be followed
up on.