Post-Donation Fainting Incident Report
Document all necessary details regarding fainting incidents occurring after a donation to ensure proper follow-up and improve donor safety.
Donor Full Name
*
First Name
Last Name
Donor Age
*
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident (e.g., donation center, waiting area)
*
Describe the fainting incident
*
Symptoms observed prior to fainting
*
Dizziness
Sweating
Nausea
Paleness
Blurred vision
Other
Actions taken by staff
*
Donor placed in recovery position
Monitored vital signs
Provided fluids/snacks
Medical attention called
Family/friend contacted
Other
Outcome of the incident
*
Donor recovered fully on site
Donor required further medical attention
Donor left with assistance
Other
Witnesses present
*
Staff
Other donors
Family/Friend
No witnesses
Other
Name of staff completing this report
*
First Name
Last Name
Staff contact email
*
example@example.com
Signature of reporting staff
*
Submit Report
Submit Report
Should be Empty: