Plasma Donation Reaction Report Form
Please complete this form to report any reactions experienced after plasma donation. Your feedback helps ensure donor safety and improve care.
Donor Full Name
*
First Name
Last Name
Donor Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
example@example.com
Donation Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Donation Center or Location
*
Time from Donation to Reaction Onset
*
Please Select
During donation
Immediately after (within 30 minutes)
Within 1 hour
1–6 hours after
6–24 hours after
More than 24 hours after
Type of Reaction Experienced
*
Mild allergic (rash, itching)
Moderate allergic (hives, swelling)
Severe allergic (anaphylaxis)
Vasovagal (fainting, dizziness)
Respiratory (shortness of breath)
Fever/chills
Pain or discomfort at needle site
Other
Describe Symptoms in Detail
*
Severity of Reaction
*
Mild (no intervention needed)
Moderate (minor intervention, e.g., observation, fluids)
Severe (medical intervention required)
Was Medical Attention Required?
*
No
Yes, on-site at donation center
Yes, at a healthcare facility (clinic, hospital)
Current Status of Donor
*
Fully recovered
Recovering, symptoms improving
Ongoing symptoms
Unknown
Additional Notes or Comments
Submit Report
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