Thank you for your interest in becoming a lifesaving milk donor!  The incredible gift of donor milk is often the only option for the most medically fragile babies. We hope this information is helpful in completing the application and approval process as quickly as possible to help feed tiny tummies!

This Donor Packet includes:

• Donor Consent Form: Please carefully review and sign.
• Donor Medical History Questionnaire:  Please carefully complete.
• Health Care Provider Release Form:  Please complete the requested healthcare provider (HCP) contact information and release, and we will contact them on your behalf to obtain a brief health history and verification that you're healthy enough to donate. The HCP sign-off is required; if we are unsuccessful at receiving it from your HCP, we may ask for your assistance.
• Donor Education (for you to keep): Blood Testing Information and Notice of Privacy Practices

Once we receive your completed Donor Packet (consent form, questionnaire, and HCP release form), we will arrange to have your blood drawn. Once we have received your blood test results  and you have completed an intake phone call, your file will be reviewed for approval.

Never hesitate to reach out with any questions and thank you for your big heart to give!

The Milk Bank Team    

 

 

 

 

Donor Medical History Questionnaire

 Donor's Health Care Provider (OB, PCP, CNM, NP)

Milk Handling

Please answer the following questions to the best of your knowledge.  (Answering "YES" to any question does not necessarily exclude you as a donor.)

Medications and Health

While many medications are safe while breastfeeding your baby, milk for donation to The Milk Bank typically goes to fragile babies who may not be able to tolerate them. Depending on the medication/vaccine, there may be a temporary exclusion.

 Please list ANY of the following you are currently taking or took while pumping your milk for donation:

• A blood transfusion (including intrauterine), blood products (e.g. platelets/plasma/packed cells)
• An organ or tissue transplant
• Any procedure using non-sterile needles, equipment, or multi-use dyes at a non-regulated site (e.g., tattoos, piercings, acupuncture, permanent makeup, microblading)
• Exposure to another person’s blood (such as through an accidental needle stick or through mucous membranes or an open wound)
• Sexual contact with a person who has ever tested positive for HIV
• Had or been treated for syphilis or gonorrhea 

• Engagement in non-prescription injection drug use
• Exchange of sex for money or drugs
• Tested positive for HIV
• Had a new sexual partner 

Lifestyle

Baby's Health History

Demographics (Optional)

The Milk Bank collects demographic data for reporting purposes and to combat disparities in healthcare.  This information will not influence your application in any way.

Milk Donor: Please confirm the bottom section and sign below.  This form gives us permission to contact your health care provider.

Dear Health Care Provider,

Your patient listed below has volunteered to be a human milk donor to The Milk Bank.  Much like blood banking, we depend on the generosity of donor moms to help combat infant mortality and save lives!  To meet the standards set by the Human Milk Banking Association of North America guidelines, we require some additional information.  TMB tests each donor for HIV-1, HIV-2, HTLV-1, HTLV-2, Hepatitis B, Hepatitis C, and Syphilis.  You will be notified of any positive test results.  Please answer the following questions as soon as possible as human milk donation is a time sensitive matter.

To the best of your knowledge, does this patient have a history of:

1.	Genital herpes?	Yes	No
2.	Blood transfusion or receiving blood products in the last 12 months?	Yes	No
3.	Hepatitis or prenatal viral infection?	Yes	No
4.	Receipt of any vaccinations in the past year?	Yes	No
5.	Taking any medication on a regular basis?	Yes	No

If  you answered Yes to questions 4 or 5 please list the vaccines or medications and dosage.

 

To the best of my knowledge, the donor listed below is in good health and would be an appropriate human milk donor.

HCP Signature

Date

PLEASE FAX COMPLETED FORM TO (317)536-1676 or email to MilkDonor@themilkbank.org

Health Care Provider Information (OB, CNM, NP)

Donor Mother Name  {donorName}	Donor Mother DOB  {dateOf181}
Provider's Name  {practiceName} {providersFull}	Provider's Address  {address374}
Provider's Phone  {phoneNumber}	Provider's Fax  {faxNumber}

I hereby request and authorize my Health Care Provider Identified above to furnish The Milk Bank access to, or copies of, medical information for my participation as a human milk donor.

Donor Consent Form

I understand and agree to the following:

1. I am voluntarily choosing to donate my milk to The Milk Bank and I understand I will not be compensated for the milk I donate. The Milk Bank relies on the generosity of our donors to help save infant lives.  In many situations, donor milk is the only option for the most medically fragile babies.

2. I intend to donate my excess breastmilk to The Milk Bank (ideally within 30 days of approval).  I agree to prioritize my own health and my infant’s health.  Should circumstances change and I am unable to donate milk, I will notify The Milk Bank as soon as possible.

3. It is my responsibility to notify The Milk Bank if:
   • I have any health or lifestyle changes
   • I need to take ANY medications
   • There is a case of illness in myself, my immediate family, or my household, including exposure to a contagious illness or disease

4. The Milk Bank is required by accreditation standards to be in communication with approved donors at least every two months.  I agree to respond to communication efforts regarding milk safety at all times while I am an active donor.

5. Approval as a milk donor does not indicate that my milk is safe to share or sell informally.  Milk from approved donors receives pasteurization and additional microbiological testing by The Milk Bank.

6. Once my milk has been donated it becomes the property of The Milk Bank and cannot be returned. The Milk Bank may utilize donated milk at the organization’s discretion including, but not limited to, dispensing to outpatients, hospitals, or nonprofit milk banks if there is a critical need.

7. I have received, read, and understand the Notice of Privacy Practices provided by The Milk Bank.  I understand that in order to respond securely to a secure email sent by The Milk Bank, I must reply within the Microsoft window that opens - not to the original email stating a protected message has been sent.

8. I have read and understood all the donor information presented to me and I have had all of my questions answered.  I hereby certify that to the best of my knowledge I understand and have answered all questions truthfully.

 

I give consent to the following:

1.  To use my donated milk or data about the milk for research or for medical treatments and therapeutics beyond hospital, NICU, or outpatient use.  I understand I may opt out by notifying The Milk Bank in writing.

2. To have my blood tested as described in Blood Testing Information and for my healthcare provider to be notified of the results if they are of medical significance.  I have read and understand all the information regarding HIV and the blood tests required to become a donor.  I do not consider myself to be a person at risk for spreading HIV.

3. If milk I plan to donate is in the possession of a hospital, I give consent for The Milk Bank staff to contact the appropriate hospital staff and divulge to them the necessary information about me (e.g. name, DOB, donor status, Donor ID number, etc.) in order to coordinate delivery of said milk to The Milk Bank.

4. To be contacted by email, voicemail, SMS/MMS text messages, or other means.  I understand message/data rates may apply and that I may opt out by notifying the Milk Bank in writing. I authorize The Milk Bank to leave messages on contact numbers that I provide.

5. To share my contact information and donor/recipient status with designated representatives for communication, fund development, or other purposes. I understand that I may opt out of sharing my information by notifying The Milk Bank in writing.

Thank you for completing the Donor Application Packet.  Please click the Submit button below.