CANAM Sperm Donor Suitability Assessment


Sperm Donor Suitability Assessment: Infectious Disease Screening

Canadian distribution of REGULAR PROCESS Donor Gametes (beginning Feb. 4, 2020)

Please read each question carefully and respond by clicking “Yes” or “No”H.C. Directive Clause 2.1.1

 

 

1.

Have you ever been diagnosed with Spongiform encephalopathy or prion-related disease, including but not limited to a diagnosis of CJD, or have you ever had a first-degree family member with history of CJD?

II(a)

 

2.

Have you ever received human growth hormone in any country other the U.S. or Canada, OR; have you received human growth hormone in the U.S. or Canada prior to 1986?

II(b)

 

3.

Have you ever received dura mater?

II(c)

 

4.

Have you ever had active encephalitis or meningitis of infectious or unknown etiology?

II(d)

 

5.

Have you ever been diagnosed with   dementia or any degenerative or demyelinating disease of the central nervous system or other neurological disease of unknown etiology?

II(e)

 

6.

Have you ever been diagnosed with active genital herpes by history and/or physical examination?

II(g)

 

7.

Have you ever experienced urethral discharge, genital warts or genital ulcers at the time of a donation?

II(h)

 

8.

Have you ever had an infection of clinical significance?

II(i)

 

9.

Have you ever experienced any major systemic disorder, including systemic malignancies which might compromise the gamete?

II(j)

If YES to Question 1-9, please provide dates and details:

 

 

10.

In the preceding 2 months, have you been infected or diagnosed with, or treated for, Neisseria gonorrhoeae or Chlamydia trachomatis infection?

II(f)1

 

11.

In the preceding 12 months, have you been diagnosed with or treated for Treponema pallidum infection?

II(f)2

 

12.

In the preceding 120 days, have you been diagnosed with WNV infection, or been suspected of WNV infection (based on symptoms and/or laboratory results or confirmed WNV viremia) following diagnosis or onset of illness, whichever is later?

II(k)

 

13a.

In the preceding 3 months (sperm donors only) or 2 months (ova donors only), have you been diagnosed with ZIKV infection, or have you resided in, or travelled to, an area with ZIKV transmission?

II(l)

 

13b.

In the preceding 3 months (sperm donors only) or 2 months (ova donors only), have you had unprotected sex with person(s) described in 13a?

II(l)

 

14.

Have you EVER experienced Question 10-13?

 

If YES to Question 14, please provide dates and details:

 

 

 

14a.

In the last five years, have you experienced nonmedical intravenous, intramuscular or subcutaneous injection of drugs?

II(m)1

 

14b.

Have you had sex with any person described in 14a in the preceding 12 months?

II(m)4

 

15.

In the preceding 3 months, have you had sex with another man?

II(m)2

 

16a.

In the preceding six months, have you engaged in sex in exchange for money or drugs?

II(m)3

 

16b.

Have you had sex with any person described in 16a in the preceding 12 months?

II(m)4

 

17.

In the preceding 12 months, have you had sex with any person known to have HIV, or clinically active HBV or clinically active HCV?

II(m)4

 

18.

In the preceding six months, have you been exposed to known or suspected HIV-, HBV-, and/or HCV-infected blood through percutaneous inoculation or though contact with an open wound, non-intact skin or mucous membrane?

II(m)5

 

19.

In the preceding six months, have you been in a correctional facility, jail or prison for more than 72 consecutive hours?

II(m)6

 

20.

In the preceding six months, have you undergone tattooing, ear piercing, or body piercing in which sterile procedures were not used?

II(m)7

 

21.

In the preceding six months, have you had close contact with another person having clinically active HBV or clinically active HCV infection?

II(m)8

 

22.

Do you have a history of infection with HIV-1, HIV-2, HTLV-1, HTLV-2, clinically active HBV or clinically active HCV?

II(m)9

 

23.

In the preceding six months, have you, or any sexual partner(s), received, blood, blood components, blood products, or other human tissues that are known to be possible sources of blood-borne pathogens?

II(m)10

 

24.

  Have you EVER experienced questions 14-23?  

IF YES to Question 24, please provide dates and details:

 

Please provide any additional details: 

DONOR: I confirm that all answers given are complete and accurate.

Donor Name:

   

Date of Birth:

 

 

 

Date Signed:

 February 24, 2020
 
Staff use:

Lab Staff Signature:

_______________________________

Date:

_______________________________

Medical Director or Designate Signature:

_______________________________

Date:

_______________________________

DONOR ID:

_______________________________

Date Completed:

_______________________________

 

Technical Requirements for Conducting the Suitability Assessment of Sperm and Ova Donors

Sperm Donor Suitability Assessment: Infectious Disease Screening

– Regular Process Donors

© 2020 CAN-AM Cryoservices Corp. All rights reserved.

Version 1

Effec. 2020/01/16

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February 7, 2020 8:26 am PSTCANAM Sperm Donor Suitability Assessment Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 73.42.152.24