transferred from one individual or location to another be marked as "Sensitive Medical
(2) Donor information that should be obtained.
(a) Legal name (include the name which may have been used at the time
of the donation, e.g., married name, maiden name, or alias).
(b) Social security number (SSN - include the number which may have
been used at the time of the donation, e.g., donors' not the sponsor's).
(d) Date of birth (DOB).
(e) Current military status.
(f) Current address and phone number of work and home to include area
(g) Location of each donation, to include: military installation, or city and
state; facility (shopping mall, high school, hospital), and type of collection site
(permanent or mobile).
(h) Type of each donation (plasma, whole blood, platelets, etc.).
(I) Date for each donation.
(j) Date that the individual was assigned in the area of donation.
(k) Date of donor's first positive HIV test.
(l) Dates of all donor's negative HIV tests for the 12-month period prior to
(m) Signed and witnessed authorization for release of information which will
be used to obtain further donor related information required for completion of the look-
back. Minimum information on release form must include the name and address of the
MTF, the donor's signature and date, and the witness' signature and date. The medical
personnel conducting the interview may witness the release form.
(3) Recipient information.
(a) Legal names of recipient (include the name which may have been used
at the time of the transfusion).