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.
- Have you taken any medications on the Medication Deferral List in the time frames indicated EXCEPT anti-platelet agents?
- In the past 12 months, have you had a blood transfusion (someone else’s, not your own blood), human bone graft or bone powder?
- 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?
- In the past 12 months, are you a male who had sexual contact with another male?
- 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)?
- In the past 12 months, have you had an ear or body piercing that did NOT involve sterile, single-use, disposable equipment?
- In the past 12 months, have you been in juvenile detention, lockup, jail, or prison for more than 72 consecutive hours?
- From 1980 to the present, did you spend time that adds up to 5 years or more in Europe?
- From 1980 through 1996, did you spend time that adds up to 3 months or more in the United Kingdom?
- Have you EVER used needles to take drugs, steroids, or anything not prescribed by your doctor?
- Have you EVER had malaria or babesiosis?