| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | name(+) | 0;1 | FREE TEXT | B | Enter the name of the collection site, group affiliation, or coded item related to donor history. | |
| .02 | screen | 0;2 | SET OF CODES | G:GROUP AFFILIATION D:DEFERRAL CODE C:COLLECTION SITE GC:GROUP AFFILIATION & COLLECTION SITE R:DONOR REACTION T:TRANSFUSION REACTION | This designates the type of donor utility. | |
| .03 | full name(+) | 0;3 | FREE TEXT | C | This is the name of the donor. | |
| 1.1 | address line 1 | 1;1 | FREE TEXT | This is the first line of the donor address. | ||
| 1.2 | address line 2 | 1;2 | FREE TEXT | This is the second line of the donor address. | ||
| 1.3 | address line 3 | 1;3 | FREE TEXT | This is the third line of the donor address. | ||
| 1.4 | city | 1;4 | FREE TEXT | This is the city part of the donor address. | ||
| 1.5 | state | 1;5 | POINTER | 5 | This is the state part of the donor address. | |
| 1.6 | zip code | 1;6 | FREE TEXT | This is the zip code part of the donor address. | ||
| 1.7 | phone 1 | 1;7 | FREE TEXT | This is the phone number of the donor. | ||
| 1.8 | phone 2 | 1;8 | FREE TEXT | This is the other phone number of the donor. | ||
| 1.9 | group leader | 1;9 | FREE TEXT | This is the person coordinating the collection site or group affiliation. | ||
| 2 | donor history | 2;0 | WORD-PROCESSING | These are the comments on donor history. | ||
| 3 | comment | 3;0 | WORD-PROCESSING | This is the comment on donor history. |