Blood Donation Reaction Report Form
Please use this form to report and document any reaction experienced after a blood donation. Complete all relevant sections to help us provide appropriate follow-up.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date and Time of Donation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time of Reaction
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Symptoms Experienced
*
Fever or chills
Rash or hives
Dizziness or fainting
Shortness of breath
Nausea or vomiting
Other
Severity of Reaction
*
Mild
Moderate
Severe
Actions Taken
Rested
Drank fluids
Notified staff
Other
Did you seek medical help?
*
Yes
No
Current Status
*
Resolved
Ongoing
Worsening
Additional Notes
Submit Report
Should be Empty: