Donors are requested to read carefully the questionnaire before registration. If any question applies to the potential donor, one might leave. No questions would be asked. However, a donor might decide to register and discusses the problem with the doctor. If the donor is not allowed to donate (deferred), in that case the donor is enlisted in a list of deferrals. This list is highly confidential and no hospital staff have access to it, except the Blood Bank administrators. Refer to the last paragraph of this questionnaire. Finally donors are requested to be truthful in their responses and should carefully note question 26.
NB. Menstruating females are not allowed to donate blood although it is omitted in the questionnaire.

Dear Sir/Madam,

We wish to thank you for your generosity, but if you fall under one of the following categories, or suffer (have suffered) from one of the following symptoms, illness, or history of illness, you are kindly asked to either refrain from donating blood or discuss your problem with the doctor.

HIGH RISK SITUATIONS

1. Is there any history of jaundice ever in your lifetime? Any hepatitis (liver disease) as far as you know?
2. Sexually transmitted illness e.g. gonorrhoea, chlamydia, syphilis, ever in your lifetime?
3. (for men only) Have you had sexual relations with other men? (whether past or present).
4. Have you had a change in sexual partners in the past six months? If not, as far as you know, has your partner had any sexual relations with other persons whether male or female?
5. Are you on any drugs? Or any other substances not otherwise with a doctors’ prescription?
6. Have you done any permanent tattoos in the past six months? Any ear piercing or some other type of body piercing, these last 6 months?
7. Any history of electrolysis/acupuncture in the past six months?
8. Have you had any history of needle stick injuries in the last six months, and or mucous membrane exposure to blood?
9. Have you been in prison in /the last three years?
10. Have you ever accepted payments for sex in money or drugs?
11. Do you have or have you had a partner who was or is in any of these group?

Personal History:-

12. Are you on any medication? Tigason for Psoriasis, Roacutane for Acne,or Proscar for the Prostate, antihypertensive medicines, antibiotics, painkillers (except paracetamol)?
13. Have you ever been on growth hormone or human gonadotrophins or others derived from human pituitary extracts?
14. Are you in good health? Do you have a cold, nasal allergies, or have you had diarrhoea in the last month?
15. Do you have a history of chest pain or shortness of breath on going upstairs or uphill?
16. Have you ever suffered from heart or lung disease? Kidney or liver failure?
17. Do you have a history of epileptic fits or acute asthmatic attacks?
18. Have you had an operation in the recent past (how long ago?) or any investigations or intervention (e.g. colonoscopy or others)?
19. Have you received a blood transfusion or any treatment involving the use of a specific blood product?
20. Are you waiting for any blood results or any other test?
21. Do you suffer from high or low blood pressure? Are you on any treatment for it?
22. Any history of infectious illnesses in the past? Chickenpox, measles or rubella (one month), brucellosis, rat typhus or leishmaniasis (three years)
23. Have you ever suffered from malaria or sleeping sickness (trypanosomiasis) or were you exposed to them during the last six months?
24. Is there a history of cancer or leukaemia? Give details if yes.
25. Have you ever suffered from genetic/hereditary conditions e.g. autoimmune conditions like diabetes on insulin or with complications?
26. Any family history of Crutzfeldt-Jacob disease (mad cow disease)?
27. Have you received any vaccinations during the last month or during the last year in the case of rabies?
28. Have you had any bone fractures, joint dislocations, burns or scalds, or an electric shock?
29. Any history of blood disorders e.g. G6PD deficiency?
30. Have you had a history of organ transplantation or a history of splenectomy due to illness

Other questions:-

31. How old are you? ( are you between 18 and 63?) over 63 years only regular donors, that is those donating at least once every 6 months, 17 year olds need a written parents consent.
32. Do you possess a Maltese I.D. card? A Maltese passport or a Maltese driving licence?
33. For how long have you been residing in Malta? (Applies both to foreigners and to Maltese living abroad? Where to? When?
34. Have you been to the United Kingdom for a cumulative period of 6 months or more between 1980 and 1996?
35. Have you ever been stopped from donating blood in this or any other blood transfusion centre?
36. Are you aware of the fact that the tests we carry out are not 100% foolproof and therefore an AIDS or Hepatitis virus infected donation might very rarely NOT be detected? Do you realise we depend on your total honesty?
37. Do you agree to allow this unit of blood to be transfused to your next of kin?
38. (Females only) Are you menstruating? Any missed period? Are you pregnant? Any history of pregnancy? Or miscarriage in the past year? Are you breast feeding?
39. Do you have a dangerous job or hobby?
40. For what reason have you come to this centre to donate blood?

If you have any doubts about any of the above please ask the doctor who will be examining you.

Please ALWAYS be honest. Rest assured of strict confidentiality. None of the information you give us can be divulged to any one without your permission.

Thank you once again.

Date _______________

Signature of Medical Officer______________________________

I, the undersigned, declare that I have read the above list of questions and none ofthem apply to me; I hereby give my permission, so that the blood which I am freely and willingly giving may be tested for all that is necessary, including the Aids Virus. I agree that I have been fully informed about the Blood Donation procedure and that, had I wanted to, I could have asked for more information. I also accept the fact that my name may be included in a strictly confidential list ofpersons who are deferred from donating blood for some reason or other.

Signature of Donor _______________________

Donor’s Name in BLOCK LETTERS ________________________

Officer Signature (Pre-Donation) ………………………….....................

The National Blood Transfusion Service operates under the following laws; The Human Blood and Blood Components Act 2005; EU Directive 2002/98EC and EU Directive 2004/33EC. All data is collected and processed in strictly in accordance to the Data Protection Act 2001, the Human Blood and Blood Components Act 2005, other subsidiary legislation and the Privacy Policy of the Department, a copy of which is available on demand.

The sensitive data* we are requesting is required for the purpose of this application. You are not obliged to give this information if you do not wish to. However, you should be aware that, should you not provide such information, the department cannot process this form. You are entitled to see the information, related to you, should you ask for it in writing and we endeavour to satisfy this request in a reasonable time. Any communications are to be addressed to the Data Controller – National Blood Transfusion Service.

* Sensitive Data refers to data, which can reveal race or ethnic origin, political opinions, religious or philosophical beliefs, membership of a trade union, health or sex life.