Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
General Health & Lifestyle
1. Are you in good general health?
*
Yes
No
2. Do you use tobacco products or nicotine in any form?
*
Yes
No
3. Do you consume alcohol?
*
Yes
No
Medical History
4. Have you had any recent infections, illnesses or surgeries?
*
Yes
No
5. Have you taken any medications during pregnancy or while breastfeeding?
*
Yes
No
6. Are you currently taking any medications?
*
Yes
No
7. Have you ever tested positive for any of the following? HIV, Hepatitis B or C, HTLV I/II, Syphilis, CMV
*
Yes
No
8. Have you traveled outside the US or Canada in the past 12 months?
*
Yes
No
9. Have you ever received a blood transfusion or organ transplant?
*
Yes
No
10. Have you or your partner ever tested positive for HIV or hepatitis?
*
Yes
No
Maternal & Infant Information
11. What is your baby's date of birth?
-
Month
-
Day
Year
Date
12. Is your baby healthy and growing well?
*
Yes
No
13. Do you have a surplus of milk beyond your baby's needs?
*
Yes
No
14. Was your baby born prematurely (before 37 weeks)?
*
Yes
No
Behavioral Risk
15. Have you ever used illegal drugs or misused prescription drugs?
*
Yes
No
16. Have you gotten a recent tattoo or body piercing within the past 12 months?
*
Yes
No
17. Have you or your partner engaged in high-risk sexual behavior in the past year?
*
Yes
No
18. Have you ever been incarcerated or lived with someone who was?
*
Yes
No
Milk Handling Practices
19. Do you store pumped milk in a clean, food-grade container (including breast milk storage bags)?
*
Yes
No
20. Do you freeze your milk immediately after pumping?
*
Yes
No
21. Are you willing to follow safe milk collection and handling guidelines provided by the milk bank?
*
Yes
No
Please provide any other pertinent information that you may deem worth sharing.
Acknowledgement & Signature
I confirm the above information is accurate to the best of my knowledge. I understand that this questionnaire is part of the eligibility screening process for becoming a breast milk donor.
Signature
*
By signing you confirm that the information provided is true to the best of your knowledge and you understand this is part of the donor eligibility screening process.
Confidentiality Notice
All information provided in this questionnaire, including your personal and health-related responses, will be kept strictly confidential. None of your answers or contact information will be disclosed to anyone outside of the authorized screening and medical review team without your explicit written consent.
Submit
Submit
Interview Date
-
Month
-
Day
Year
Date
DC Decision
Please Select
Proceed
Hold
Decline
DC Notes
Status
*
Please Select
Lead – Prescreen Received
Interview Completed
MRR Signed
Labs – Ordered
Labs – Pass
Labs – Fail
Labs – Review (Hold)
Active – Cleared
Shipment – Attestation Signed
Shipment – Kit Requested
Shipment – Kit Shipped
Shipment – In Transit
Shipment – Processed
Shipment – Cleared
QC Hold
Exited
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