Schedule 1 Blood donor certificate

Schedule 1 Blood donor certificate

(Clause 6(1))

(Human Tissue Act 1983, section 20D)

Questions

(Please circle your answers)

| 1 | To the best of your knowledge, have you ever thought you could be infected with HIV or have AIDS? | Yes/No | | 2 | To the best of your knowledge, have you ever had a test which showed you had hepatitis B, hepatitis C, HIV or HTLV? | Yes/No | | 3 | To the best of your knowledge, in the last 5 years, have you “used drugs” by injection or been injected with drugs not prescribed by a doctor or dentist? | Yes/No | | 4 | In the last 12 months, have you had an illness with both a rash and swollen glands, with or without a fever? | Yes/No | | 5 | In the last 3 months, have you engaged in sexual activity with someone who—(a) you think could be infected with HIV or have AIDS?(b) had a test which showed they had hepatitis B, hepatitis C, HIV or HTLV?(c) ever “used drugs” by injection or has been injected with drugs not prescribed by a doctor or dentist?(d) had an illness with both a rash and swollen glands, with or without a fever? | Yes/No | | 6 | In the last 12 months, have you had sexual activity with a new partner who currently lives or has previously lived overseas? | Yes/No | | 7 | In the last 3 months, have you had sex (with or without a condom) with a man who you think may have had oral or anal sex with another man? | Yes/No | | 8 | In the last 3 months, have you had male-to-male sex (that is, oral or anal sex) with or without a condom? | Yes/No/I am female | | 9 | In the last 3 months, have you been a sex worker (eg received payment for sex in money, gifts or drugs)? | Yes/No | | 10 | In the last 3 months, have you engaged in sexual activity with a sex worker? | Yes/No | | 11 | In the last 12 months, have you been imprisoned in a prison or held in a lock-up or detention centre? | Yes/No | | 12 | In the last 4 months, have you had a blood transfusion? | Yes/No | | 13 | In the last 12 months, have you had (yellow) jaundice or hepatitis or been in contact with someone who has? | Yes/No | | 14 | In the last 4 months, have you been injured with a used needle (needlestick)? | Yes/No | | 15 | In the last 4 months, have you had blood or other bodily fluid come into contact with your eyes, mouth, nose or to broken skin? | Yes/No | | 16 | In the last 4 months, have you had a tattoo, body and/or ear piercing or acupuncture? | Yes/No |

I declare that I have understood the information on this form and have answered the questions in the declaration honestly and to the best of my knowledge. I understand that there are penalties, including fines and imprisonment, for providing false or misleading information.

Donor (please print)