Donor Questionnaire

What is the Record of Donation?

The Record of Donation is a form that captures all relevant information about you and your donation, and follows you from the registration process, through screening to giving blood. It includes a confidential questionnaire that helps determine if you are eligible to give blood. After donation, it then travels with the unit of blood and sample through testing, processing and final use. What You Must Know Before filling out the donor questionnaire we ask you to read the What You Must Know to Give Blood, or the What You Must Know to Give Plasma or Platelets brochure. The brochure information will help you understand what to expect during your donation and includes some details on post-donation care.

Record of Donation form

Completing Your Questionnaire

Help us make the most of your time and donation! When you come in to donate blood, be sure to complete your Record of Donation by shading in the boxes on the form for questions one through 13. Shading instead of ticking the boxes has shown to reduce incomplete questionnaires. For safety reasons, incomplete questionnaires may result in a donation not being used. Thank you for your cooperation!

Impact on Your Eligibility

An affirmative response to any of the Record of Donation questions does not necessarily mean that you are ineligible to donate. Once you have responded in writing to questions one through 13, a trained health professional will determine your eligibility during a confidential one-on-one interview with you at the blood donor clinic.

Information Recorded on the Record of Donation

• Your donor identification and address



• Your blood type, preferred language, and number of previous donations



• Results of physical tests including hemoglobin, blood pressure, and temperature



• Indication of how the unit will be processed



• Indications of which employees served you



• Your answers to questions on health and certain high-risk activities



• Comments by screening employee



• Confidential Unit Exclusion (CUE) label



• Deferral codes, if applicable



• Relevant details of the venepuncture and bleed time



• Unit labelling information



• Your signature, confirming your informed consent to use the blood collected and that you have answered all questions truthfully.

For more information about the Record of Donation, please speak to a nurse at your local blood donor clinic, or call 1 888 2 DONATE
(1 888 236-6283) and ask to speak with a member of our medical staff.

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