Convalescent Plasma Registration of Interest Form About youWhat best describes your circumstances in relation to COVID-19?*I tested positive for COVID-19 and was hospitalisedI tested positive for COVID-19, but was not hospitalisedI have had a positive COVID-19 antibody test result.I had symptoms of COVID-19, and self-isolatedThank you for your interestAt this time we can only accept donations from members of the public who have tested positive for COVID-19.Electronic Care Record (ECR) Consent*In order to confirm your COVID-19 diagnosis we need to ask for your consent for NIBTS to access your ECR. Your information will only be used to confirm your eligibility to participate in the trial and will remain confidential. Details about how we use your information can be found on our website at nibts.hscni.net/privacy. Copies of our Donor Privacy Notice are available at donation sessions or by emailing the Data Protection Officer at firstname.lastname@example.org I consent for NIBTS to assess my ECR.I do not consent for NIBTS to assess my ECR.Thank you for your interestOnly a confirmed positive COVID-19 diagnosis can be processed through this trial at this point.Have you previously donated with NIBTS?*YesNoPlease enter your Donor Number if known (optional)The format of the Donor Number is R0XXXXXXAre you aged between 17 and 66 years old?*YesNoThank you for your interestUnfortunately, you can only become a blood donor between your 17th and 66th birthday. If you're a regular donor aged 66 or over and in good health, you can keep donating.Do you weigh more than 7stone 12lbs (50kg) and less than 25 stone (158kg)?*YesNoThank you for your interestUnfortunately, you must weigh more than 7stone 12lbs (50kg) and less than 25 stone (158kg) to be eligible to donate.Are you pregnant, or have you had a baby, miscarriage or a termination in the last 6 months?*YesNoThank you for your interestA period of six months must have passed before you would be eligible.Have you had a blood or blood product transfusion since 1st January 1980?*YesNoThank you for your interestUnfortunately, you're not eligible to give blood if you have received (or think you might have received) a blood transfusion since 1980.Have you got, or have you had, any heart conditions?*YesNoThank you for your interestUnfortunately, you're not eligible to give blood. Many thanks for your support. If you'd like more information, please get in touch.Your personal detailsName* First Last Date of birth (dd/mm/yyyy)*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex*MaleFemalePrefer not to sayEmail* Phone Number*Address* Street Address Address Line 2 City ZIP / Postal Code Consent*I consent to be contacted by NIBTS to assess my eligibility.EmailThis field is for validation purposes and should be left unchanged.