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COVID-19 Convalescent Plasma Donor Pre-Screening

Franciscan Health is supporting Versiti in its efforts to collect plasma from recovered COVID-19 patients to help treat others diagnosed with the virus.  Please complete and submit the form below. Your information will be provided to a Franciscan representative who will help you to complete the Versiti pre-screening process.

Thank you for your interest in being a donor of COVID-19 convalescent plasma.

Did you receive a Covid-19 test at a Franciscan Health facility?*
Are you a Franciscan Alliance employee*

Thank you for your interest in being a Covid-19 plasma donor. Since your test was not conducted at a Franciscan Health facility, please contact Versiti directly to process your request. Instructions can be found at www.versiti.org/covid19plasma or by calling 1-866-702-4673.

Donor Name*
Date of Birth*
Address*
1. Did you (donor) have a positive CoVID-19 test result (molecular diagnostic test) while you were ill?*
Positive Test Date
Optional

A positive test result is required to move forward with the pre-screening process.  Please contact Versiti at 866-702-4673 for assistance or questions.

2. Did you (donor) have a positive serological test for SARS-CoV-2 antibodies?*
Positive Serological Test Date
Optional
3. Date when you (donor) became symptom-free? *
4. Have you (donor) been symptom-free for at least 14 days?*
5. Were you hospitalized for CoVID-19?*
6. Have you ever been pregnant?*

Authorization to Disclose and Use Identifiable Protected Health Information for a Research Study

Introduction:  You have the right to decide who may review or use your Protected Health Information ("PHI").  The type of information that may be used is described below.

Acknowledgment: I have recovered from COVID-19 and I am interested in donating plasma that will be administered as part of a research study.  The purpose of the study is to see if the antibodies in my plasma help other patients to recover.  I understand that more information is needed to determine if I can donate plasma for COVID-19 treatment than with a normal plasma donation.

PHI Uses/Disclosures: I authorize Franciscan Health:

  • To obtain my COVID-19 test results from my medical record
  • To disclose those results as well as the information I provided in the previous questionnaire (demographic information, responses to questions about current and past COVID-19 symptoms, disease history that could impact donation ability, etc.) to Versiti (plasma donation center).

I have the right:

To refuse to sign this form.  Not signing the form will not affect my regular health care including treatment, payment, or enrollment in a health plan or eligibility for health care benefits.  However, not signing the form may prevent me from donating plasma for COVID-19 treatment.

To review and obtain a copy of my personal health information collected during the research study. 

To cancel this release of information/authorization at any time. If I choose to cancel this release of information/authorization, I must notify in writing at: Franciscan Health, Attn: Legal Department, 421. N Emerson Avenue, Greenwood, IN 46143 However, even if I cancel this release of information/authorization, information may already have been shared.

To receive a copy of this form upon request.

Due to the COVID-19 pandemic, it was not recommended that the individual present at Franciscan Health to complete this paperwork.  I have had the opportunity to review and ask questions regarding this release of information/authorization.  By electronically signing this release of information/authorization, I am confirming that it reflects my wishes.

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Patient was not testing at a Franciscan Health facility but is interesting in being tested.

Medical Professional Sign-Off

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Address*
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