Title Page

  • Hospital Name

  • Conducted on

  • Prepared by

  • Location

Blood Donation

  • Instructions:
    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:

  • Email:

  • Phone:

  • Home Address:
  • Occupation:

  • 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:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.