Questionnaire for the RKP donation

Thank you for your willingness to donate blood plasma. We are pleased that you would like to support us in the treatment of COVID-19 patients.

Please fill out the form below (the fields marked with * are mandatory) and please also note the data protection information: Please read the privacy policy carefully here and confirm that you agree to the use of your data by clicking the confirmation box at the bottom of the form.

Note: This short list of questions does not replace the detailed donor questionnaire or the confidential consultation with a physician. Persons with sexual risk behavior may have to be deferred from donating blood due to legal regulations. The decision on your suitability to donate is the responsibility of the medical staff at the donation appointment.

Form for plasma donors

Would you be willing to donate convalescent plasma?: *

Surname, first name: *

Date of birth: *

Street, house number: *

Town, zip code: *

Telephone number: *

Cell phone: *

E-mail address: *

Have you tested positive for SARS-CoV-2 (virus detection)?: *

When did your symptoms begin (fever, cough, etc.)?: *

Since when have you been symptom-free?: *

Has a retest shown a negative result?: *

If yes, when was the test carried out?:

Do you suffer from a previous illness (cardiovascular problems, epilepsy, cancer, etc.)?: *

If yes, which one?:

Are you currently taking medication (birth control pills or other hormonal contraceptives are excluded)?: *

If yes, which one?:

Have you ever received a blood transfusion (red blood cells, platelets, blood plasma - including autologous blood)?: *

If yes, when was the last time?:

In the last 4 months, have you had a tattoo or any other procedure that injures the skin or mucous membrane such as piercing, ear piercing, permanent make-up, body modification?: *

For women only: Have you ever been pregnant?:

For women only: Are you pregnant or breastfeeding?:

Did you stay in the United Kingdom of Great Britain and Northern Ireland for more than 6 months in total between 01.01.1980 and 31.12.1996?: *

Have you had surgery or a blood transfusion (red blood cells, platelets, plasma) in the United Kingdom of Great Britain and Northern Ireland after 01.01.1980?: *

Were you born abroad?: *

Have you ever lived abroad for more than 6 months?: *

If yes, when and where?:

Have you been abroad in the last 6 months, even for a short time?: *

If yes, where?:

Have you ever donated blood or plasma?: *

If yes, have there been any complications with a previous donation?:

If yes, which?:

I have taken note of the following information obligations, which fully inform me about the use of the data provided via the contact form: My personal data will be stored and processed on the server of the MHH data center in accordance with data protection regulations, in particular the GDPR. The Institute of Transfusion Medicine and Transplant Engineering has access to the data. The processing of the personal data provided by me serves to establish contact for a possible RKP donation. My data will also be used for COVID-19 research projects to gain insights into new therapeutic approaches. My personal data will only be passed on within the MHH to those departments and persons who need this data to fulfill contractual and legal obligations or to implement the legitimate interest of the MHH. My personal data will not be passed on to a third country or an international organization. After collection, my data will be stored by the Institute of Transfusion Medicine and Transplant Engineering, MHH for as long as necessary to fulfill the purpose. After completion of the COVID-19 research projects, my personal data will be deleted or anonymized. Existing retention obligations and periods will be observed. In the event of a revocation, my data that I have provided via the contact form will be deleted. In the data protection declaration linked above the form, I have taken note of my legal rights with regard to the personal data concerning me in accordance with the GDPR. *