Post-Donation Reaction Report Form
Please provide feedback about your experience after donating. Your responses help us improve donor care and safety.
Date and time of your donation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
How did you feel immediately after your donation?
*
Great
Okay
Tired
Dizzy or lightheaded
Other
Did you experience any physical reactions?
*
None
Bruising at donation site
Nausea
Fainting
Sweating
Other
Did you experience any emotional reactions?
*
None
Anxiety
Relief
Happiness
Regret
Other
Did you have any issues or concerns after your donation?
*
No issues
Yes, minor concerns
Yes, serious concerns
If you had issues or concerns, please describe them
Did you require any assistance after your donation?
*
No
Yes, from staff
Yes, from others
How serious do you feel your reaction was?
*
1
2
3
4
5
Would you like someone to follow up with you about your experience?
*
No follow-up needed
Yes, please contact me
Additional comments or suggestions
Submit Report
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