Blood Donor Clinic in Orleans St Peter Catholic HGigh School,Saturday April 08, 2017 9.30am -1.30pm


Blood Donor Clinic in Orleans Saturday April 08, 2017 9.30am -1.30pm

St Peter Catholic High School, 750 Charlemagne Blvd

Q1.    ______________        __________________           _______________

Last Name                              First name                   Middle name


Q3.    _______________

Phone number & postal code


Q4.   Age Group (are you above 17?)          _______                _______

YES                   NO


Q5   Country of origin and date of Birth   ________________


Q6.  Have you ever had Malaria (in your life time)?     _____    ______        _________

YES                   NO             Do not Know


Q7. Have you travelled to high risk countries/area after April 08, 2016?      _____          _____                                                                                                                                   YES        NO

Q8.  If your stay was more than consecutive six month in high risk area, was it ended before

April 08, 2013.


____                _______           ___________________

Yes                      NO               Departure month and year

From the area (if you know)


Q9   If your stay was less than six months in the high risk area, was it ended before

 April 08, 2016.


_____                  _____                 _____________________

Yes                          NO                      Departure month and year

From that area (if you know)


Q10 Are you already a blood donor.             ______                  ______

YES                      NO


IF YES, Your CARD NUMBER   ________________________



Q11.   Your Preferred time for donation     _____________


Regarding Malaria areas, there are more than 100 countries that are considered at risk so I will only mention a few that may affect your members. Any members travelling to at risk countries since April 8, 2016 will not be eligible to donate:

  • India – risk in all areas
  • Bangladesh – all areas are at risk except the city of Dhaka
  • Pakistan – risk in all areas
  • Saudi Arabia – Jeddah, Makkah, Medina, Tai’f and Riyadh are risk free
  • Iran & Iraq – risk in all areas
  • Egypt, Jordan, Lebanon, Kuwait – no risk
  • Syria – no risk
  • Somalia – risk in all areas

The complete list for Zika and Malaria can be found on CBS website:
Click on the “Can I donate link?” to find the lists.


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