Infected Blood Incident Inquiry Questionnaire
Please complete this questionnaire if you have been affected by or have information regarding incidents involving infected blood. Your responses will help support the inquiry process.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Incident (if known)
-
Month
-
Day
Year
Date
Location of Incident (e.g., hospital, clinic, region)
Type of Exposure or Incident
*
Transfusion
Organ Transplant
Medical Procedure
Other (please specify)
Please indicate the health impact(s) you experienced as a result of the incident.
*
No apparent impact
Short-term illness
Long-term/chronic illness
Hospitalization
Other (please specify)
Please rate the impact of the incident on your life.
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Are you aware of others who may have been affected by the same or similar incident?
Yes
No
Prefer not to say
Please provide any additional information or describe the incident in your own words.
Upload any supporting documents or evidence (optional)
Upload a File
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How satisfied are you with the way your case or similar cases have been addressed so far?
1
2
3
4
5
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