Blood Donation

1. Fill out the details needed and answer "Yes", "No" for the questions below.
2. Add photos and notes by clicking on the paperclip icon.
3. Complete audit by providing digital signature.

Blood Donor Information

Donor's Name:

Date of Birth:



Home Address:


Blood Type:

Did you ever donate blood before?

When was the last time you have donated blood?
Health Security Check

Do you suffer of any diseases?

Please specify disease(s):

Other diseases:

Do you have allergies?

Please specify allergies:

Other allergies:

Have you ever had positive Blood test for HbsAg, Hcv, HIV?

Please specify:

Do you have any cardiac problems?

Do you suffer any bleeding disorders?

Please specify:

Do you take medication?

Please describe the medication you take:

I want to donate blood voluntarily and will not be entitled to claim any exchange for my donation. I guarantee that all the provided information is true. I understand the questions, which are for my protection as well as to protect the recipient of my blood. Donor's Signature:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.