Blood Donors Registration :: Rashtrotthana Blood Centre

Name*

Aadhaar/OtherID Number

Your ID number will help us to track your donation

Gender

Male

Female

Marital status

Married

Unmarried

Date of birth

Age

Eligiblity Criteria

Blood Group

Blood Group will be verified after donation

Weight

Eligiblity Criteria

Occupation

Father/Husband name

Address

City

Pincode

Mobile Number

If you provide the contact details, it help us to contact you for if any adjective result of the blood

Have you donated previously

Yes

Would you like to be a regular donor?

Yes

Did you have any discomfort after donation?

Yes

Would you like to be contacted during emergency requirement of blood?

Yes

Do you feel well today?

(To be filled during the donation process.)

Did you have something to eat in the last 4 hours?

(To be filled during the donation process.)

Did you sleep well last night?

(To be filled during the donation process.)

(Note: Before blood donation, one should have adequate food, a minimum six hours of sleep is a must, if not one may have to face into word reaction)

Have any reason to believe that you may be infected by either Hepatities, Malaria, HIV/AIDS or venereal diseases?

Yes

Are you on any medication?

Yes

Eligiblity Criteria

In the last 6 months have you had any history of the following?

● Unexplained weight loss
● Continious Low-grade fever
● Repeated Diarrhoea
● Swollen Glands

● Tattooing Ear Piercing
● Blood Transfusion
● Dental Extraction
● Minor Surgery

Yes No

Are you taking or have taken any of these in the past 72 hours?

● Steroids
● Aspirin

Yes No

Have you taken any Antibiotics in past 15 days?

Yes

Are you under the influence of Alcohol?

Yes No

Are you suffering from any of the following diseases?

● Cancer/Malignant Disease
● Heart Disease
● Abnormal bleeding tendency
● Unexplained weight loss
● Diabetes controlled on insulin
● Hepatities B/C

● Chronic Nepehrities
● Sexually trans diesease
● Liver Disease
● Tuberculosis
● Polycythemia vera
● Asthama

● Epilepsy
● Leprosy
● Schizophrenia
● Endocrine disorders
● Allergic disease
● Hypo/Hyper tension

Yes No

If there any history of the following mentioned past 1 year?

● Hepatities in family or close contact
● Typhoid
● Dog bite/Rabies vaccine
● Blood Transfusion (Individual/Spouse)

● Major surgery
● Immunoglobulin
● Jaundice
● Tattooing/Body Piercing/Acupuncture (Individual/Spouse)

Yes No

In the past 15 days have been vaccinated?

● Cholera
● Typhoid
● Diphtheria

● Tetanus
● Plague
● Gammagloulin

Yes No

Eligiblity Criteria

Is there any history of Malaria or Duly treated?

Yes

Have you come from abroad in the last 28 days / from the area declared as Covid-19 infected by the Ministry of Health & Family Welfare/Have You come in contact with any person from this area? Have you iuffered from Covid- 19 infection? lf so, Have you completed 28 days of home isolation?

Yes

For women donors, are you in the following state:

● Are you pregnant
● Are you having your periods today?
● Have you had an abortion in the last 6 months
● Do you have a child less than one year old

Yes No

I understand that
a) Blood donation is totally voluntary act and no inducement or remuneration has been offered.
b) Donation of blood/components is a medical procedure and that by donating voluntarily, I accept the risk associated with this procedure.
c) The surplus plasma component will be utilised for fractionation and derivation of essential plasma derived medicines.
d) My blood will be tested for Hepatitis B, Hepatities C, Malaria Parasite, HIV/AIDS and venereal diseases in addition to any other screening tests required to ensure blood saftey.
e) Any abnormal tests results will be informed at the address furnished.
I prohibit any information provided by me or about my donation to be disclosed to any individual or government agency without my prior permission.

I have read and understood all the information presented and answered all the questions truthfully. I have acknowledged that any incorrect statement or concealment may affect my health or may harm the recipient.

Rashtrotthana Blood Centre

Principal Sponsor: Smt. Subhadraben Jayantilal Nagardas Shah (Jain)

Blood Donation form