Milk Donor Pre-Screen 08.2023

Milk Donor Prescreen

There is no greater gift to a family of a fragile NICU baby than donor milk. Milk donations are more than just nutrition, they are life-saving medicine! Over 1,000 lifesavers each year answer the call to save a life!

Because we serve critically ill infants, milk donors must meet specific safety requirements before milk can be accepted. This includes:

In good health and not using tobacco products, CBD oil, marijuana, or recreational drugs.
At low risk, along with their sexual partner(s), for communicable diseases (i.e. HIV/AIDS, Hepatitis B or C, or Syphilis).
Collecting extra breastmilk beyond what your baby needs or milk that cannot be used by your baby.

Please complete the prescreen below. If you’d prefer to speak with a donor coordinator you can reach us at (317)536-1670.

First Name*

Last Name*

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Donor's Date of Birth*

Baby's Date of Birth*

Why are you interested in donating milk? (please select 1 which most closely matches your reason)*

OversupplyI want to help other babiesBaby refuses bottle or baby sensitivity/allergy to breastmilkI am a surrogateI experienced infant loss and am exploring bereavement donation options

Please help us ensure the safety of the milk we provide to tiny NICU warriors by answering the following questions to the best of your knowledge. (Answering “YES” to any question does not necessarily exclude you as a donor.)

Have you ever had brain surgery that included receiving a human cadveric (allogenic) dura mater (brain covering) graft?*

YesNo

Have you ever been diagnosed with Creutzfeldt-Jacob Disease (CJD), Variant Creutzfeldt-Jacob Disease (vCJD, commonly known as “mad cow disease”), or any other transmissible spongiform encephalopathy (TSE)*

YesNo

Do you use any nicotine/tobacco or cannabis/marijuana/CBD products on an ongoing basis? *

YesNo

In the past 12 months, have you used any recreational/illegal drugs such as, cocaine, ecstasy, LSD, Dexedrine, or injectables? *

YesNo

Do you have a history of cancer, leukemia, lymphoma (including Hodgkin’s disease), or Kaposi sarcoma?*

YesNo

Explain when, what type, and treatment:

Have you ever had HIV, Hepatitis B or C, or HTLV? *

YesNo

Please list all ONGOING medications you took or plan to take for the majority of the time you were/will be pumping for donation, even if you believe them to be safe for breastfeeding:*

Would you like an interpreter?*

YesNo

What is your preferred language?

I consent to The Milk Bank contacting me 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 all contact numbers and information that I provide.*

YesNo

How did you hear about us?

Health Provider Referral (Hospital, Lactation Consultant, Doula, Pediatrician, OB/GYN, etc)Health Organization (WIC, other milk bank, blood bank)Personal Contact (Friend, family)Internet Search (Including The Milk Bank website)Social MediaOutreach Event (Conference, Expo, Fair, etc)Media (TV, newspaper, etc)My EmployerGoogle Ad

I'm a prior:

DonorRecipient

What was your donor number?

Is there anything else you'd like to let us know or ask?