Living Kidney Donor Screening Form
*= required field
If you have documentation of your blood type (Blood donor card or a medical record printout, please return a copy of blood type documentation to:
Transplant Clinic c/o Living Donor Coordinator
701 Park Avenue, B1.310 Minneapolis, MN 55415
Or fax to 612-873-1334, ATTN: Living Donor Coordinator
Living Donor High Risk Behavior Questions
Per health requirements set by United Network of Organ Sharing we are required to collect information about potential donors to assess possible exposure to HIV, Hepatitis B or Hepatitis C. This is done to ensure safety and maintain informed consent. The list of statements below contains behaviors that are considered high risk and are used to assess possible exposure to HIV, Hepatitis B or Hepatitis C. The definition of “had sex” refers to any method of sexual contact, including vaginal, anal and oral contact. Please review the statements and check either “none of these apply” or “one or more of these apply.” Please sign and date the questionnaire.
This information is confidential and will not be disclosed without your consent.
- I have had sex with a person with known or suspected HIV, Hepatitis B, or Hepatitis C in the preceding 12 months.
- I am a man who has had sex with another man (MSM) in the preceding 12 months.
- I am a woman who has had sex with a man with a history of MSM behavior in the preceding 12 months.
- I have had sex in exchange for money or drugs in the preceding 12 months.
- I have had sex with a person who had sex in exchange for money or drugs in the preceding 12 months.
- I have had sex with a person who injected drugs in their blood, muscle, or skin for nonmedical reasons in the preceding 12 months.
- I have injected drugs into my blood, muscle, or skin for nonmedical reasons in the preceding 12 months.
- I have been in lockup, jail, prison, or a juvenile correctional facility for more than 72 consecutive hours in the preceding 12 months.
- I have been newly diagnosed with, or have been treated for syphilis, gonorrhea, Chlamydia, or genital ulcers in the preceding 12 months.
- Though not applicable to living kidney donors:
- I am child who is 18 months of age or less and born to a mother known to be infected with, or at increased risk for, HIV, HBV, or HCV infection.
- I am child who has been breastfed within the preceding 12 months and the mother is known to be infected with, or at increased risk for, HIV infection
- I have been on hemodialysis in the preceding 12 months