Please note: In order to schedule a convalescent plasma donation, you must begin the process by filling out this prescreening form. If you have questions, please call 866-CV-PLSMA (866-287-5762).  Please answer all required questions.

Before completing the form below, please review the following questions and indicate whether you answered "YES" to any.

  1. Have you taken any medications on the Medication Deferral List in the time frames indicated EXCEPT anti-platelet agents?
  2. In the past 12 months, have you had a blood transfusion (someone else’s, not your own blood), human bone graft or bone powder?
  3. In the past 12 months, have you come into contact with someone else’s blood (on non-intact skin or mucous membranes) or had an accidental human needle stick?
  4. In the past 12 months, are you a male who had sexual contact with another male?
  5. In the past 12 months, have you had a tattoo in the following states (CT, GA, ID, MD, MA, NH, NY, PA, UT, WY, or DC)?
  6. In the past 12 months, have you had an ear or body piercing that did NOT involve sterile, single-use, disposable equipment?
  7. In the past 12 months, have you been in juvenile detention, lockup, jail, or prison for more than 72 consecutive hours?
  8. From 1980 to the present, did you spend time that adds up to 5 years or more in Europe?
  9. From 1980 through 1996, did you spend time that adds up to 3 months or more in the United Kingdom?
  10. Have you EVER used needles to take drugs, steroids, or anything not prescribed by your doctor?
  11. Have you EVER had malaria or babesiosis?

STEP ONE: CONFIRM YOU MEET GENERAL PLASMA DONOR REQUIREMENTS



STEP TWO: CONFIRM YOU’VE TESTED POSITIVE FOR COVID-19








STEP THREE: TELL US ABOUT YOUR EXPERIENCE WITH COVID-19

















"Within the 14 days before symptoms, I had close contact (within 6 feet for ≥15 minutes) with an individual with lab-diagnosed COVID-19 (e.g. lived with, worked with, cared for)."


"Within the 14 days before symptoms, I was in a group within which several people became ill with highly-suspected or lab-diagnosed COVID-19."


STEP FOUR: TELL US ABOUT YOURSELF




By checking the box below, I acknowledge that I am at least 18 years of age, and I agree and consent to Vitalant sharing this information with health care providers or hospitals participating in a COVID-19 convalescent plasma program.