| Document Date: 2014-07-06 21:40:30
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Company I130 (identify previous malaria residency) Yes No Malaria Travel / / Country Isle of Man / Northern Ireland / Falkland Islands / Australia / United Kingdom / Scotland / Wales / / Facility Blood Donor Centre / / IndustryTerm needle site / blood products / heavy machinery / / MedicalCondition bruise / cuts / leptospirosis / familial insomnia / syphilis / HIV / chest pain / chickenpox / genital herpes / shingles / rheumatoid arthritis / Transmittable Diseases / Chagas’ disease / Status Malaria / thyroid disorder / hepatitis C / hepatitis B / temporary numbness / low blood pressure / injury / miscarriage / hepatitis / bowel disease / illness / Tiredness / lupus / infections / head injury / Q fever / infertility / abdominal pain / iron deficiency / Yes No Previous malaria / Creutzfeldt-Jakob disease / cancer / acne / kind including melanoma / Fainting / malaria / stroke / diabetes / fever / pain / Nerve irritation / vomiting / autoimmune disease / diseases / rheumatic fever / blood clot / AIDS / epilepsy / Infection / cough / thrombosis / serious illness / rash / chest pain/angina / Gerstmann-Straussler-Scheinker syndrome / tuberculosis / blood disorder / / MedicalTreatment blood transfusion / ear piercing / acupuncture / vaccinations / / NaturalFeature Channel Islands / Ross River / / OperatingSystem L3 / / Organization Human Research Ethics Committee / Blood Donor Centre / Australian Red Cross Blood Service / Blood Service / / Person Katy Gallagher / / / Position general practitioner / female sex worker / Governor / dentist / MLA Minister / ACT Parliamentary Counsel / No Capillary Hb / / Product ibuprofen / M-16 / / URL www.legislation.act.gov.au / /
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Australian Capital Territory Blood Donation (Transmittable Diseases) Blood Donor Form[removed]No 1) Disallowable instrument DI2012–68 Approved form AF2012–113