CONFIDENTIAL Please bring this form to your session

LONDON UNIVERSITY STUDY OF VOLUNTARY BLOOD DONORS

(If you have any difficulty in completing this form, Miss West, State , Registered Nurse, will be at your session to help you and to collect your form.)

1. How many blood donations have you your given? ……. What is your blood group? ……

2. Have you ever received a blood transfusion? Yes …… No ……. (Please tick correct answer)

3. Have any of the following persons (not including yourself) ever given or received blood? Please write ‘yes’ or ‘no’ in the appropriate space. Cross out those parts which do not apply.

4. Please tick on the list below the main reason why you give blood?

• …… a. General desire to help people

• …… b. To repay in some way a transfusion given to someone I know

• …… c. In response to an appeal for blood

• …… d. Some of my friends/colleagues give blood and encouraged me to join them

• …… e. Another reason (please state)

5. Could you say why you first decided to become a blood donor?

Please write in the space below.

6. What more do you think the service could do to persuade people to be blood donors? Any suggestions you may have which might make the need for donors better known would be appreciated.

Please write in the space below.

In order to sort out the information we obtain into various groups of voluntary blood donors, we would like to know a little about your family background. We would be grateful, therefore, if you would answer the following questions. We would remind you that we DO NOT ask for your name or address and it is NOT entered on this form.

10. How many children have you? ……

11. In which country were you born?

12. What is the occupation of the chief earner in your family and in what industry or type of business does he or she work?

13. If you are not the chief earner in the family what is your occupation and industry?