Sperm Donor Application PDF Details

The Sperm Donor Application Form represents a vital and comprehensive document designed to ensure the safety, compatibility, and ethical alignment of sperm donations with the needs of recipients. This detailed form encompasses an array of sections meticulously structured to gather critical information about potential donors. It starts with basic identification details, such as the donor's name, age, and citizenship status, and then delves into more personal territories like marital status and current health insurance coverage. Key components of the application include thorough inquiries into the donor's personal and family medical histories, donation history, and any previous engagements in similar programs. Additionally, it addresses lifestyle habits, including substance use, alcohol consumption, and exposure to various environmental factors, to ascertain the overall health and suitability of the donor. The form also places emphasis on legal and behavioral history, aiming to screen for any factors that might impact the donor's ability to contribute. By requesting detailed medical, personal, and lifestyle information, this form plays a crucial role in the donor screening process, ensuring that only individuals who meet strict criteria are considered for donation, thereby safeguarding the health and welfare of both donors and recipients.

QuestionAnswer
Form NameSperm Donor Application
Form Length27 pages
Fillable?No
Fillable fields0
Avg. time to fill out6 min 45 sec
Other namesapply for sperm donor, sperm donor registration, sperm donor vacancy, sperm doner online apply

Form Preview Example

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 1

 

 

 

 

 

 

UNIFORM DONOR APPLICATION FORM

Date filled out: _____/_____/_____

(Month/Day/Year)

Compensation you are requesting $___________

To become a sperm or egg donor, we need to learn some information about your personal and medical history. Your responses to these questions will help us to make sure that your health and medical history are compatible with the donation process and in particular for egg donors that it will not involve any increased risks for you. This effort will also help us to match you to an appropriate recipient.

Please provide complete and accurate information to these questions. If you do not know the answer, ask a parent or family member. Any information you provide during the donation process, will remain completely confidential. Some of the information from this questionnaire will be given to the recipient(s) as noted but all identifying information is removed.

A “yes” response will not necessarily eliminate you as a potential donor. Most people will have at least one of these conditions in themselves or a family member. The accuracy of the information you will be giving will provide information to potential families you may help to create.

Instructions:

1.Please fill in all blanks completely. Please complete all questions and write “N/A” if not applicable.

2.Please be specific. Avoid expressions such as “natural” or “old age” (for causes of death). List any health

problems as specifically as possible. If you do not know the age, put the approximate age or ask a relative to help you. List exact relationships such as “first cousin through my mother’s sister”.

3.Please provide information on all the relatives requested. Do not write their names.

4.If you have any questions, please call your donor coordinator.

 

 

 

NAME AS IT APPEARS ON YOUR DRIVER’S LICENSE

 

Last name: __________________________

First name: ___________________ Middle Initial: _____

 

Sex: Male ______ Female ______

Age: _______

 

Date of Birth: ____/____/____ Place of Birth:_________________

 

Soc. Security #: ______-______-________

Are you a US citizen or permanent resident? Yes

No

Driver’s License #:______________________

State:__________

 

Marital Status: ____single ____married ____ divorced ____ widowed ______engaged _____partnered

Length of Current Relationship: _____ years

Nation Wide Egg Donation Application 08/2011

Donation Application Form NWED DONOR NUMBER __________________________________

Page 2

DEMOGRAPHICS

MAILING ADDRESS:

Street: __________________________________________________City: ______________________________

State/Province: ____________ Zip/ Postal code: _______________ Country: ______________

 

 

 

OK to leave message?

Home Phone Number:

(

) _______- ________

Yes

No

Work Phone Number:

(

) _______- ________

Yes

No

Cell Phone Number:

(

) _______- ________

Yes

No

Email Address:

__________________________________________________

Do you have medical insurance? ____Yes

____No

 

If yes, name of carrier: ____________

ID #:______________

Group #__________________

Employer: ________________________________________________________________________________________

DONATION HISTORY:

Have you applied or been screened to be an egg or sperm donor before? ____Yes ____No

If yes, list name and location of donor program (s): _____________________________________________________

_________________________________________________________________________________________________

Have you donated before? ____Yes ____No If yes, how many times did you donate or cycle? ____

Are you currently enrolled as an egg or sperm donor in another program? ____Yes ____No

How did you hear about our program?

Radio (which station)_________________

Friend (name)______________________

Newspaper (which one) _______________ Magazine (which one)___________________

Website (which one) ________________

Other (specify)____________________

 

Did you consult with your family when completing your family medical history? _____Yes

_____No

I hereby attest that all information disclosed in this application is accurate, true, and up-to-date to the best of my

knowledge. ___________________________________________________________________________

(Signature of Applicant)

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 3

 

 

 

 

 

 

PERSONAL HEALTH HISTORY

Are you currently under a physicians care for any reason? _____Yes _____No

If yes, please explain: ________________________________________________________________________

Have you ever had any major illnesses such as amoebic dysentery (infection of the intestine), hypertension, blood clots, pneumonia, mononucleosis, etc.? ____Yes ____No

If yes, when? _______________________________________________________________________________

Have you had any serious illness in the past? _____ Yes _____ No

If yes, please describe: ______________________________________________________________________________

Did you have any complications or concerns with anesthesia? _______________________________________________

Have you had any hospitalization(s) not mentioned above? _________________________________________________

_________________________________________________________________________________________________

Please list any surgical procedures:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Have you ever had any broken bones? _____Yes _____ No If yes, please list: _____________________________

How many days in the preceding 12 months did you miss work because of illness (colds, flu, accidents, surgery, etc.)? Please explain:____________________________________________________________________________________

Has anyone in your family, including yourself, experienced recurring and/or chronic physical symptoms that have not been evaluated by a physician (Please include those symptoms that you may not consider serious.)? _____Yes _____No

If yes, please describe:______________________________________________________________________________.

Have you ever been seen by psychiatrist, psychologist, social worker, counselor, or any other mental health professional for any reason? ____Yes _____No

If yes, when, for how long and for what reason? ____________________________________________________

Have you ever used medications such as antianxiety or antidepressants to treat an emotional or psychological problem?

____Yes ____No

If yes, list why and date last used _______________________________________________________________

Have you been vaccinated in the last 6 months? _____Yes _____No

If yes, what were you vaccinated for? ___________________________________________________________

List all medications that you have taken in the proceeding 12 months (prescription):

Medication

How Often

Reason

____________________

_________

_____________________________________________

____________________

_________

_____________________________________________

____________________

_________

_____________________________________________

____________________

_________

_____________________________________________

Nation Wide Egg Donation Application 08/2011

Donation Application Form NWED DONOR NUMBER __________________________________ Page 4

PERSONAL HEALTH HISTORY (continued)

List all current over-the-counter medications (include hormones, vitamins, aspirin, antacids, laxatives, herbal & sports

supplements, performance-enhancing supplements including steroids, etc.)

Medication

How Often

Reason

____________________

_________

_____________________________________________

____________________

_________

_____________________________________________

____________________

_________

_____________________________________________

____________________

_________

_____________________________________________

Have you ever taken anti-malarial drugs or had malaria?

_____Yes

_____No

Have you had a blood transfusion?

_____Yes

_____No

If yes, when? _______________

Have you ever been refused or denied as a blood donor? _____Yes

_____No If yes, why? ____________________

Are you eligible to work in the United States? _____Yes

____No

Is your work schedule flexible? ____Yes ____No

List all the jobs you held in the past five years:

 

 

 

 

 

 

 

 

 

Jobs/Duties

Year Began

Year End

 

 

Have you had radiation exposure or x-ray exposure? _____Yes _____No

If yes, please explain: ________________________________________________________________________

Have you ever been exposed to “agent orange” or any other herbicides or chemicals (military, forestry, highway service,

or elsewhere)? _____Yes

_____No

 

If yes, which substance(s)? ____________________________________________________________________

When? __________________________________

Where? ______________________________________

In the preceding six months, were you exposed to the following in your job, living environment or while involved in hobbies? If yes to any of these, give dates and how often you have been exposed. Please consider carefully.

Exposed to:

 

Response

When?

How Often?

Toxic Chemicals or Substances

 

Yes

No

 

 

Sprays

 

Yes

No

 

 

Fumes/Exhaust

 

Yes

No

 

 

Radiation

 

Yes

No

 

 

Flea Powder/Sprays

 

Yes

No

 

 

Lead/Lead products

 

Yes

No

 

 

Asbestos/Asbestos products

 

Yes

No

 

 

Pesticides/Herbicides

 

Yes

No

 

 

Cleaning solutions/solvents

 

Yes

No

 

 

 

 

 

 

 

 

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 5

 

 

 

 

 

 

PERSONAL HEALTH HISTORY (continued)

Do you take hot baths, saunas, hot tubs, or steam baths? _____Daily _____Weekly _____Occasionally _____Never

Within the past 6 months have you been exposed to UV rays in a tanning booth? _____ Yes

_____ No

What is your caffeine usage? Number cups of coffee: _____ Soda _____ Tea _____ Energy Drinks _____

Do you currently smoke cigarettes? Daily

Occasionally Rarely

Never If yes, how many per day? _____

Have you ever smoked cigarettes? ____Yes ____No

 

 

If yes, how many cigarettes per day? __________

 

 

If no, what year/month did you stop? __________

 

 

How many years did you smoke? _____

 

 

What best describes your alcohol consumption? ____Never drink

 

 

____ Rarely drink/Drink in small amounts

____Even amounts through the week ____Drink in concentrated periods

What type of alcohol do you usually consume? _____Beer _____ Wine _____Liquor

 

If you do drink, how many drinks do you usually consume in a week?

____1-3 ____4-9 ____10-15 ____16 or more

Have you ever used recreational or illicit drugs (cocaine, marijuana, LSD, heroin, barbiturates, narcotics, opiates,

amphetamines, hallucinogens, tranquilizers, PCP, steroids, or etc.)?

_____ Yes _______ No

 

If yes, which one (s) and when did you last use them? _______________________________________________

Do you sleep well? _____Yes _____ No

If no, how do you manage this?__________________________________

Have you had acupuncture, ear and/or body piercing or tattooing in which sterile procedures may not have been used?

____Yes _____No

Please list and describe all of your tattoos and body piercings:

Date Received:

Description:

Location on Body:

Sterile Needles Used?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had any problems with the law (i.e. DUI, custody issues, lawsuits)? _____Yes _____No

If yes, please explain _________________________________________________________________________

Please list any arrests, convictions, sentences, etc.: ________________________________________________

__________________________________________________________________________________________

Have you ever been incarcerated? If yes, please describe__________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 6

 

 

 

SEXUAL AND CONTRACEPTIVE HISTORY

Sexual Orientation (please circle): Homosexual Heterosexual Bisexual

Number of current sexual partners: ______Number of sexual partners during the last six months: ______

Total number of past sexual partners: ______

In the last 6 months have you had unprotected sex (intercourse without a condom) with a new partner? ___Yes ___No

Have you ever injected drugs or had a sexual partner who did so? ____Yes ____No

 

CONTRACEPTIVE HISTORY:

 

 

 

Currently use: IUD Type _____

Diaphragm _____

Condom _____

Birth Control Pills _____

Rhythm _____ Spermicide _____ Depo-Provera _____ Tubal Ligation _____ None _____

If Birth Control Pills: __________________________ (name)

How long on Birth Control Pills? ___________________

Why did you start taking Birth Control Pills? ___________________________

 

If Depo-Provera, when was your last injection? _________________________

To your knowledge, have you or any of your sexual partners been in contact with anyone or have you been personally tested or been treated for any of the following:

Self

Partner If yes, when: How many times? When was the last time?

HIV (AIDS)

NSU (non specific urethritis)

Syphilis

Gonorrhea

Chlamydia

Trichomonas

Venereal Warts

Herpes, Genital

Viral Hepatitis B or C

Genital Sores

Penis Discharge

Other sexually transmissible diseases

Nation Wide Egg Donation Application 08/2011

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 7

 

 

 

 

 

 

 

 

 

 

 

MENSTRUAL AND REPRODUCTIVE HISTORY: FOR EGG DONORS

 

 

 

 

 

 

 

 

 

 

 

 

 

Age at onset of menses: _______

 

Date of Last Menstrual Period: ____________

 

Are your menstrual periods regular: _____Yes

_____No

 

 

 

 

How long is your monthly cycle (first day of one period to first day of the next)? ________days

 

 

 

Are you periods regular when you are not on any type of hormonal birth control such as the pill, etc.? ____Yes

____ No

 

If no, how many times per year do you menstruate? ___________

 

 

 

How many days does your period usually last? ______ days

 

 

 

 

Do you bleed or spot between periods? _____Yes _____No

 

 

 

Do you get menstrual cramps before, during, or after your period? ____Yes ____No

 

 

 

If yes, are your cramps: mild

moderate

severe?

 

 

 

If yes, do you use medication alleviate the pain? _____Yes

_____No

 

 

If yes, what medications do you use? ____________________________________________________________

Have you ever had any medical treatment for menstrual problems? ___________________________________________

Date of last Pap Smear: ________________ Result: ____________________________________________________

Have you ever had an abnormal PAP: __________________ If yes, when & why: _______________________________

Have you ever been told you were infertile: ______________ If yes, when & why:________________________________

Have you ever had a pelvic infection requiring treatment with antibiotics ____Yes ____No

Do you want children in the future? ____Yes ____No

REPRODUCTIVE HISTORY (or partner for sperm donors)

FERTILITY HISTORY:

 

 

 

 

 

 

Number of pregnancies:___________________

 

 

 

 

 

Number of miscarriages: __________________

Date(s) of miscarriages: ___________________________________

Number of ectopic pregnancies: _____________

Date(s) of ectopic pregnancy: _______________________________

Number of abortions: _____________________

Date(s) of abortions_______________________________________

Number of stillbirths: _____________________

Date(s) of each stillbirth: ___________________________________

Number of children: ______________________

Are you Currently Breastfeeding? ____Yes

____No

 

Length of time it took you or your partner to get pregnant. Shortest _____________

Longest ______________

 

 

 

 

 

 

 

Pregnancy #

Delivery

Type of Delivery

 

Complications

Weeks pregnant

Height /

Boy/Girl

Date

(Vaginal or C-

 

 

when delivered

Weight

 

 

Section)

 

 

(prematurity)

 

1

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

Nation Wide Egg Donation Application 08/2011

Donation Application Form NWED DONOR NUMBER __________________________________

Page 8

Please note that the remaining portion of this application will be shared and viewed by recipients.

Please pay attention to the fact that the Intended Parents will be viewing your responses and your handwriting. Please make sure your writing is neat and legible.

Nation Wide Egg Donation Application 08/2011

 

 

Donation Application Form NWED DONOR NUMBER __________________________________

Page 9

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICAL CHARACTERISTICS

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Are you adopted? ____Yes ____No

 

Blood Type if known: ____________

Height: _______ Weight: ______

Date of Birth____________________

Recent weight loss/gain?____Yes ____No

If yes _______lbs loss/gain (circle one)

What was your weight at age 21? _______

 

Please circle responses that best describe you below:

Right Handed

 

Left Handed

 

Ambidextrous

 

 

 

 

Bone Structure:

Small

Medium

 

Large

Very Large

 

 

 

 

Complexion:

Very Fair Fair

Light

 

Medium

Olive Light Brown

Dark Brown Ebony

 

 

Tan ability:

None Slight

Medium

Easy

Freckle

 

 

 

 

 

Skin Condition:

Oily

 

Medium

Dry Combination

Dimples? ____Yes ____No

 

Eye Color:

Blue

 

Brown

 

Lt. Brown

Dark Brown

Green

 

Hazel

Eye set: Narrow

Average

 

Wide

 

Eye Size:

Small

Average

Large

Shape: Round

Oval Almond

Natural Hair Color:

Black

Light Blonde

Medium Blonde Dark Blonde

Light Brown

Medium Brown

 

 

Dark Brown

Red

 

 

 

 

 

 

 

Hair Type: Curly

Wavy

Straight

Hair Texture:

Fine

Medium

Coarse

Fullness:

Thin

Medium Thick

Baldness: ____ Yes ____No

 

Baldness in Family: ____ Yes ____ No

 

 

 

Premature Graying: ____Yes ____No

 

If yes, at what age____

 

 

 

 

Body and Facial Features:

Small

Medium

Large

 

 

 

 

 

Condition of your teeth: Poor

 

Fair

Good

Excellent

 

 

 

 

Have you had any periodontal or orthodontic work? ____Yes

____No If yes, at what age? _____

 

Hearing (without corrective aids):

Poor

Fair

 

Good

Excellent

 

 

 

Vision (without corrective lenses):

Poor

Fair

 

Good

Excellent Prescription (If known): _________

Nation Wide Egg Donation Application 08/2011

Donation Application Form NWED DONOR NUMBER __________________________________

Page 10

PERSONAL HEALTH HISTORY

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Do you wear glasses or contacts or have you had laser surgery? _____Yes _____No

If yes, are/were you: _____Nearsighted _____Farsighted ____Other (specify):____________

Do you have astigmatism (blurred vision due to an irregularity in the curvature of the cornea.? ____Yes ____No

If yes, age diagnosed ______.

 

Do you have any Allergies?

_____Yes

_____No

If yes, are they to: ____Food(s)_____Medication(s) _____Environmental _____Latex

Please list any childhood allergies that you have outgrown: _________________________________

For each medication allergy, describe specific substance and reaction(s) and age first noticed:

Substance: ____________________

Reaction(s):_________________________

Age: _____

Substance: ____________________

Reaction(s):_________________________

Age: _____

Substance: ____________________

Reaction(s):_________________________

Age: _____

SOCIAL HISTORY AND HABITS

THIS PAGE WILL BE SHARED AND VIEWED BY RECIPIENTS

Religion Born Into: _____________________________

Religion Practiced:_____________________________

Grade Point Average (GPA): ___________

SAT Scores: Verbal _____ Math _____

ACT Score: _____

Education:

_____

Did not Complete High School

 

 

 

_____

Received GED

 

 

 

 

_____

Completed high school

 

 

 

 

_____

Currently in college, pursuing degree in _____________________________________________

 

_____

Completed college, degree in _________________________________ GPA:______________

 

_____

Currently pursuing an advanced degree in ___________________________________________

 

_____

Completed advanced degree in ____________________________________________________

Did you have any learning disabilities or weaknesses in school? If yes, describe: ________________________________

Academic Strengths (i.e. math, reading):________________________________________________________________

How many languages do you speak? _______________Which one (s): ________________________________________

Musical Talent or Instrument: _____________________________________________________Years Experience______

Nation Wide Egg Donation Application 08/2011

How to Edit Sperm Donor Application Online for Free

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Step 1: Choose the orange button "Get Form Here" on this web page.

Step 2: You're now equipped to enhance sperm job for apply. You have lots of options thanks to our multifunctional toolbar - you'll be able to add, remove, or alter the content, highlight its particular areas, as well as carry out similar commands.

You have to type in the next details to fill out the document:

sperm donor jobs gaps to fill in

Put the required details in the If you have any questions please, NAME AS IT APPEARS ON YOUR DRIVERS, Last name First name Middle, Sex Male Female, Age, Date of Birth Place of Birth, Soc Security Are you a US, Drivers License State, Marital Status single married, Length of Current Relationship, and Nation Wide Egg Donation segment.

If you have any questions please, NAME AS IT APPEARS ON YOUR DRIVERS, Last name  First name  Middle, Sex Male  Female, Age, Date of Birth  Place of Birth, Soc Security   Are you a US, Drivers License  State, Marital Status single married, Length of Current Relationship, and Nation Wide Egg Donation in sperm donor jobs

Put down the necessary data as you are within the Donation Application Form NWED, Page, DEMOGRAPHICS, MAILING ADDRESS, Street City, StateProvince Zip Postal code, Home Phone Number, Work Phone Number, Cell Phone Number, OK to leave message, Yes, Yes, Yes, Email Address, and Do you have medical insurance Yes segment.

Completing sperm donor jobs part 3

Explain the rights and obligations of the parties inside the box If yes name of carrier ID Group, Employer, DONATION HISTORY, Have you applied or been screened, If yes list name and location of, Have you donated before Yes No If, Are you currently enrolled as an, How did you hear about our program, Friend name Magazine which one, and Did you consult with your family.

sperm donor jobs If yes name of carrier  ID  Group, Employer, DONATION HISTORY, Have you applied or been screened, If yes list name and location of, Have you donated before Yes No If, Are you currently enrolled as an, How did you hear about our program, Friend name  Magazine which one, and Did you consult with your family fields to fill

Finish the file by reading all these sections: I hereby attest that all, knowledge, Nation Wide Egg Donation, and Signature of Applicant.

stage 5 to entering details in sperm donor jobs

Step 3: Hit the Done button to be sure that your completed file can be exported to every electronic device you use or forwarded to an email you indicate.

Step 4: Produce duplicates of your document. This is going to protect you from forthcoming issues. We cannot see or distribute your information, so be certain it will be secure.

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