Donor History and Statement of Health

Donor's name*

First NameMiddle name or initialLast Name

Email*

example@example.com

Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your date of birth

Date

Infant's name

Infant's date of birth*

Date

Infant's gestational age at birth

How did you hear about Madison Area Donor Milk Alliance?

On behalf of infants in our community, Madison Area Donor Milk Alliance, Inc. is deeply grateful for your generous gift of milk. We appreciate your answers to the questions below. They may offer opportunities for clarification or discussion.

All information provided on this form is strictly confidential.

Many milk recipients ask to send the donor a “thank you.” Are you comfortable sharing your contact information with recipients?*

YesNo

Do you consume less than 24oz of caffeinated drinks per day? Intake of more than this may cause wakefulness or fussiness in babies.*

YesNo

At the time of pumping, did you smoke cigarettes, vape any substance, or chew tobacco? If yes, please explain.*

YesNo

Comment

At the time of pumping, did you use alcohol, marijuana, cocaine, ecstasy, LSD, or other recreational or social substances? If yes, please explain.*

YesNo

Comment

Do you or any member of your family now have (or did have at time of pumping) HIV, Hepatitis B, Hepatitis C, Syphilis, Lyme Disease, or any other serious illness? If yes, please explain.*

YesNo

Comment

At the time of pumping, were you taking any medications, such as hormonal contraception, an antidepressant, anti-anxiety medication, antibiotic, anti-fungal, thyroid medication, laxatives, allergy medicine, etc?*

YesNo

Please list names, dosages and dates of your medications.

During your pregnancy or while lactating, did you receive a smallpox or yellow fever vaccine? If yes, please share the dates of vaccination.*

YesNo

Date of vaccination of smallpox or yellow fever.

While lactating, have you had an active tuberculosis infection? If yes, please share more about the dates of infection, treatment, and follow up testing.*

YesNo

Comment

In the past 12 months, have you or a sexual partner been at high risk of HIV/AIDS, HTLV, or hepatitis (including anyone with hemophilia, anyone who has used a needle for the injection of illegal or nonprescription drugs, or anyone who has multiple sexual partners)? If yes, please share more about your safety practices, including frequency of STI testing.*

YesNo

Comment

In the past 12 months, have you or a sexual partner been stuck with a non-sterile needle (including anyone who has been accidentally stuck with a contaminated needle, anyone who has gotten a tattoo or piercing by someone who is not a professional or who is otherwise considered lay or suspected to use non-sterile equipment, or anyone who has received other services with non-sterile needles)? If yes, please share more about your follow up precautions.*

YesNo

Comment

Do you have any lactation or general health questions or concerns not addressed here that you would like to inform or consult with us about?*

YesNo

Comment

Do you acknowledge and understand that once you have given our organization your milk, you will not get it back nor are you guaranteed to be a recipient of donor milk from our organization should you ever need it in the future?*

YesNo

By my signature below, I confirm my understanding of and agreement with all of the following:

All information reported on this form is true and correct to the best of my knowledge.

The sharing of human breast milk carries inherent risks and maintaining optimal health practices, including safe handling and storage of pumped milk, is paramount. I agree to notify Madison Area Donor Milk Alliance in the event that my health status changes, or that I discover exposure to substances, medications and/or illnesses that may make my milk unsuitable for donation or that may have affected donated milk in the past. In the event of health status changes, I agree to refrain from donating unless cleared to do so by MADMA. I have read and fully understand the MADMA document, “Donor Guidelines for Pumping and Handling”. I have also read the MADMA document, “Recipient Waiver and Release”.

I agree to avoid alcohol for at least 12 hours prior to pumping milk for donation. I agree to use no illegal drugs and no tobacco or nicotine for the duration of time I am collecting milk for donation.

I hereby freely and voluntarily donate my milk to Madison Area Donor Milk Alliance, Inc.

Signature*

Today's date

Donor History & Statement of Health

Madison Area Donor Milk Alliance, Inc.