Blood Donation Adverse Event Inquiry Form
Report and document any adverse events experienced after a blood donation. Please fill out all sections accurately to help us improve donor safety and care.
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
Donation Location
*
When did you first notice the adverse event?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What symptoms did you experience?
*
Dizziness or lightheadedness
Fainting
Nausea or vomiting
Bruising or hematoma
Pain or discomfort
Allergic reaction (rash, itching, swelling)
Other
Please describe the adverse event in detail
*
What treatment or response was provided (if any)?
*
Preferred method for follow-up contact
*
Email
Phone
No follow-up needed
Submit
Should be Empty: