+------------------------------------------------------+----+----+----+
|                                                      | Y  | No |    |
|                                                      | es |    |    |
+------------------------------------------------------+----+----+----+
| 1.  Are you feeling healthy and well today?          |   |   |    |
+------------------------------------------------------+----+----+----+
|                                                      |    |    |    |
+------------------------------------------------------+----+----+----+
| 2.  Have you read the educational materials and had  |   |   |    |
|     your questions answered?                         |    |    |    |
+------------------------------------------------------+----+----+----+
|                                                      |    |    |    |
+------------------------------------------------------+----+----+----+
| In the past **48 hours**                             |    |    |    |
+------------------------------------------------------+----+----+----+
| 3.  Have you taken aspirin or anything that has      |   |   |    |
|     aspirin in it?                                   |    |    |    |
+------------------------------------------------------+----+----+----+
|                                                      |    |    |    |
+------------------------------------------------------+----+----+----+
| In the past **6 weeks**                              |    |    |    |
+------------------------------------------------------+----+----+----+
| 4.  Female donors: Have you been pregnant or are you |   |   |   |
|     pregnant now? (Males: check "I am male.")        |    |    | I  |
|                                                      |    |    | am |
|                                                      |    |    | ma |
|                                                      |    |    | le |
+------------------------------------------------------+----+----+----+
|                                                      |    |    |    |
+------------------------------------------------------+----+----+----+
| In the past **8 weeks** have you                     |    |    |    |
+------------------------------------------------------+----+----+----+
| 5.  Donated blood, platelets or plasma?              |   |   |    |
+------------------------------------------------------+----+----+----+
| 6.  Had any vaccinations or other shots?             |   |   |    |
+------------------------------------------------------+----+----+----+
| 7.  Had close contact with the smallpox vaccination  |   |   |    |
|     site of someone else?                            |    |    |    |
+------------------------------------------------------+----+----+----+
|                                                      |    |    |    |
+------------------------------------------------------+----+----+----+
| In the past **16 weeks**                             |    |    |    |
+------------------------------------------------------+----+----+----+
| 8.  Have you donated a double unit of red cells      |   |   |    |
|     using an apheresis machine?                      |    |    |    |
+------------------------------------------------------+----+----+----+
|                                                      |    |    |    |
+------------------------------------------------------+----+----+----+
| Since your **last donation** have you                |    |    |    |
+------------------------------------------------------+----+----+----+
| 9.  Had any new medical problems or diagnoses?       |   |   |    |
+------------------------------------------------------+----+----+----+
| 10. Had any new medical treatments?                  |   |   |    |
+------------------------------------------------------+----+----+----+
| 11. Taken any of the medications on the Medication   |   |   |    |
|     Deferral List?                                   |    |    |    |
+------------------------------------------------------+----+----+----+
| 12. Been outside the United States or Canada?        |   |   |    |
+------------------------------------------------------+----+----+----+
| 13. Come into contact with someone else's blood?     |   |   |    |
+------------------------------------------------------+----+----+----+
| 14. Had an accidental needle-stick?                  |   |   |    |
+------------------------------------------------------+----+----+----+
| 15. Had sexual contact with anyone who has HIV/AIDS  |   |   |    |
|     or has had a positive test for the HIV/AIDS      |    |    |    |
|     virus?                                           |    |    |    |
+------------------------------------------------------+----+----+----+
| 16. Had sexual contact with a prostitute or anyone   |   |   |    |
|     else who takes money or drugs or other payment   |    |    |    |
|     for sex?                                         |    |    |    |
+------------------------------------------------------+----+----+----+
| 17. Had sexual contact with anyone who has ever used |   |   |    |
|     needles to take drugs or steroids, or anything   |    |    |    |
|     [not]{.underline} prescribed by their doctor?    |    |    |    |
+------------------------------------------------------+----+----+----+
| 18. Had sexual contact with anyone who has           |   |   |    |
|     hemophilia or has used clotting factor           |    |    |    |
|     concentrates?                                    |    |    |    |
+------------------------------------------------------+----+----+----+
| 19. Female donors: had sexual contact with a male    |   |   |   |
|     who has ever had sexual contact with another     |    |    | I  |
|     male? (Males: check "I am male.")                |    |    | am |
|                                                      |    |    | ma |
|                                                      |    |    | le |
+------------------------------------------------------+----+----+----+
| 20. Had sexual contact with anyone who was born in   |   |   |    |
|     or lived in Africa?                              |    |    |    |
+------------------------------------------------------+----+----+----+
| 21. Had sexual contact with a person who has         |   |   |    |
|     hepatitis?                                       |    |    |    |
+------------------------------------------------------+----+----+----+
| 22. Lived with a person who has hepatitis?           |   |   |    |
+------------------------------------------------------+----+----+----+
| 23. Received money, drugs, or other payment for sex? |   |   |    |
+------------------------------------------------------+----+----+----+
| 24. Male donors: had sexual contact with another     |   |   |   |
|     male, even once? (Females: check "I am female.") |    |    | I  |
|                                                      |    |    | am |
|                                                      |    |    | fe |
|                                                      |    |    | ma |
|                                                      |    |    | le |
+------------------------------------------------------+----+----+----+
| 25. Had a tattoo?                                    |   |   |    |
+------------------------------------------------------+----+----+----+
| 26. Had ear or body piercing?                        |   |   |    |
+------------------------------------------------------+----+----+----+
| 27. Been in juvenile detention, lockup, jail, or     |   |   |    |
|     prison for more than 72 hours?                   |    |    |    |
+------------------------------------------------------+----+----+----+
| 28. Used needles to take drugs, steroids, or         |   |   |    |
|     anything [not]{.underline} prescribed by your    |    |    |    |
|     doctor?                                          |    |    |    |
+------------------------------------------------------+----+----+----+
| 29. Have any of your relatives had Creutzfeldt-Jakob |   |   |    |
|     disease?                                         |    |    |    |
+------------------------------------------------------+----+----+----+