Mothers' Milk Bank CA Donor Packet

Thank you for your interest in becoming a donor with The Mothers' Milk Bank. Your generous gift of breastmilk has the potential to save the life of a sick or premature infant. We are deeply grateful for your willingness to help, and we are here to guide you through each step of the process. Additionally, you'll have direct access to your donor coordinator, who will be happy to answer any questions or concerns you may have.

As part of our commitment to ensuring that babies receive safe and high-quality nutrition, we've enclosed the following:

Consent form in accordance with HIPAA and data protection laws.
Consent form for collecting your blood sample.
- We work with agencies across California and the U.S. that will conduct the necessary blood tests free of charge.
Yes/No questionnaire regarding your medical history.
All donors are required to have their primary care physician or obstetrician verify their health status by signing our medical clearance form.

If you have any questions or concerns at any point, please don't hesitate to reach out. You can contact us at 877-375-6645 ext. 3, Monday through Friday, from 8:30 a.m. to 4:30 p.m. PST.

DONOR CONSENT PRIVACY AND CONFIDENTIALITY FORM

I have voluntarily chosen to donate my breast milk to the Mothers’ Milk Bank. I understand that I will not be paid for the milk I donate. I am also aware that my milk will not be sold, but a processing fee will be charged to the recipient of the milk. My milk or data about my milk may be used for research purposes.
I will make every effort to see that my milk is donated according to the instructions provided. I understand that it is my responsibility to notify the Mothers’ Milk Bank:
1. if I, my baby, or a member of my household becomes ill
2. when I take any new medications or herbal or dietary supplements
3. when family obligations preclude continuing donations
4. when I have any questions about being a donor
5. when I have been exposed to a contagious illness or disease
I am aware that once my milk has been donated it becomes the property of the Mothers’ Milk Bank and cannot be returned to me.
I authorize that test results shall be sent by confidential e-mail, regular mail, or fax to Mothers’ Milk Bank from the laboratory or my health care provider.
I understand that a sample of my milk will be tested for bacteria before and after pasteurization.
I have read all of the information about HIV and the blood tests done for donors. I do not consider myself to be a person at risk for spreading infectious diseases.
I agree to have my blood tested as described in Blood Tests for Milk Donors and understand that I and a health care provider of my choice will be notified if the results are of medical significance.
I understand that I am encouraged to discontinue donating milk anytime my participation interferes with my own family’s needs.
I have read and understood all the donor information presented to me and had my questions answered. I hereby certify to the best of my knowledge that I understand and have answered all the questions truthfully.
I understand that acceptance by The Mothers’ Milk Bank as a donor is in no way an indication that my milk is safe to share with individuals outside the milk bank process. Milk banks take several steps to assure the safety of donor milk beyond health screening of the donor. Therefore, it is a misrepresentation to use the Milk Bank screening process to guarantee the safety of my milk for a recipient if it has not gone through processes like those used by a donor milk bank.
I understand that all donor information is confidential and protected. Health information may be disclosed to your primary health care provider if information discovered in the screening process needs further evaluation, treatment or education. I acknowledge I’ve been given the opportunity to read and review the Department of Health and Human Services Security and Privacy Administrative Standards in the Federal Register CFR Part 164.506 Mothers’ Milk Bank follows in accordance with HIPAA and understand I have a right to review this before signing below. I understand I have aright to request how my information is used, but the Mothers’ Milk Bank may disagree with the request restrictions. I have the right to revoke this authorization and consent, in writing, at any time, however, issues of public health may require disclosure.
This office reserves the right to amend our privacy policy, whether required by law or otherwise, and a revised notice may be obtained by calling our office or by physically coming into our office.
I authorize this office to leave messages on my answering machine or by e-mail regarding protected health information.

Donor's Name:*

Signature:*

Date:*

(Optional) Designated Party Authorization for Release of Medical Information:

Some patients prefer that other individuals especially family members, be allowed access to their medical information. In order to comply with strict legal standards, a written release is required to allow another person access to your medical records. This release grants permission to individual(s) listed below to: make or confirm appointments, have access to my medical charts and laboratory findings, and serve as my emergency contact. This permission applies to telephone and answering machine messages as well as other means of communication and will be in effect unless I notify this office of any change or revocations.

Would you like to authorize someone to access your medical information?

YesNo

Designated Party:

Phone Number:

Relation:

BLOOD TESTING FOR PROSPECTIVE DONORS

All prospective donors must undergo blood testing if the required tests have not been completed by their attending healthcare provider within six months prior to approval. Testing is provided at no cost to the donor.

REQUIRED TESTING

The following disease-causing agents are tested for: HIV 1 & 2, HTLV 1 & 2, Hepatitis B, Hepatitis C, Syphilis

While these tests are highly accurate, false positives can occur, and retesting is determined by our medical team. If any test result is reactive, including false positives, we may not accept or use your milk unless you have been retested and received a negative result.

Consent & Confidentiality

I understand the risks of HIV transmission and do not consider myself at risk of spreading HIV.
I consent to have blood drawn for HIV, HTLV, Hepatitis B & C, Syphilis, and any other necessary tests as determined by the Medical Director/Advisory Committee.
If any test result is reactive, the healthcare provider listed on my screening form will be notified to discuss my confidential results.
Reactive results are reportable to the State Department of Health.

Signature:*

Date:*

Date of application:*

Donor's Name:*

First NameLast Name

Birth Date:*

Ethnicity and Race:

Phone Number: *

Email Address:*

Address:*

Unit/ Apartment Number:

City:*

State:*

Zip Code:*

When do you plan to return to work:

Present or past occupation:

Baby's Name:

Baby's Birth Date:*

Baby's Current Age:

Baby's Gestational Age (i.e. 24-41 weeks):*

Is the baby home?*

YesNo

If baby is currently hospitalized, provide hospital contact's:

Phone number of hospital or contact:

During the time you collected milk, were you, the baby, and other members of your household healthy?*

YesNo

If NO, please explain:

Are you still collecting milk?*

YesNo

Was the expressed milk stored in the freezer?*

YesNo

If refrigerated first, was the milk in the refrigerator LESS than 96 hours (4 days) before moving it to the freezer?*

YesNo

Has your milk been thawed, heated, scaled or boiled?*

YesNo

Mother's Health Care Provider (OB-GYN/Midwife/Primary Care Provider)

Health Care Provider's Name:*

Phone:*

Fax Number:*

Address:*

City:*

State:*

Zip:

Doctor Contact Preference:

I will contact my doctorPlease contact my doctor

Are you a Kaiser patient?*

YesNo

*If Kaiser patient, please provide the following information:

Medical Record Number (MRN):

MEDICAL HISTORY: Medications taken

1. Have you taken Soriatane (acitretin), and/or Tegison (etretinate) in the last 3 years?*

YesNo

If yes, please explain:

2. Have you taken Proscar (finateride) or Accutane (isotretinoin) during childbearing years?*

YesNo

If yes, please list dates:

3a. Have you taken any medications, including pain medications (over-the-counter or prescription), vitamins, botanical dietary supplements (herbal products) since giving birth?*

YesNo

If yes, please list what you were taking, dosage, and dates:

3b. Did you take any medications, including pain medications (over-the-counter or prescription), vitamins, botanical dietary supplements 2 months prior to giving birth?*

YesNo

If yes, please list:

MEDICAL HISTORY: Previous illnesses/diagnoses

4. Have you had jaundice (yellow skin and eyes), liver disease, or hepatitis?*

YesNo

If yes, please explain:

5. Have you ever been treated for tuberculosis (TB)?*

YesNo

If yes, please list treatment and date(s):

6. Have you ever had heart disease or high blood pressure?*

YesNo

If yes, please explain, list medication(s) and date(s):

7. Do you have a history of yeast infections (oral, vaginal, or systemic) or unexplained white sores or lesions in the mouth?*

YesNo

If yes, please explain, include medication and dates:

8. Have you experienced autoimmune diseases such as lupus, arthritis or migraines?*

YesNo

If yes, what medications are you taking?

9. Have you had a skin disease or unexplained skin lesions, e.g. melanoma, impetigo, shingles?*

YesNo

If yes, what medication(s) do you take to treat the condition?

10. Have you ever received human cadaveric (allogenic) dura mater (brain covering) transplant?*

YesNo

11. Have you been diagnosed with variant Creutzfeldt Jakob disease (vCJD), Creutzfeldt Jakob disease (CJD) or any other transmissible spongiform encephalopathy (TSE), or have a blood relative diagnosed with genetic CJD?*

YesNo

12. Do you have a personal history of cancer?*

YesNo

If yes, what type and how and when was it treated?

13. Have you ever been told not to donate blood or milk?*

YesNo

If yes, please explain including the dates of deferral:

14. In the last 12 months have you had surgery, been hospitalized or been under a doctor’s care for a major illness?*

YesNo

If yes, list any medications used and dates of use:

15. Do you have or have you had unexplained weight loss, persistent diarrhea, fever, or night sweats?*

YesNo

16. Do you have or have you had unexplained enlarged lymph nodes?*

YesNo

PREGNANCY & POSTPARTUM

17. During this pregnancy, delivery and post-partum period did you have any complications, such as infection, excessive bleeding, or high blood pressure?*

YesNo

If yes, please explain, including medication(s) used and dates medication(s) was taken:

18. Have you had any breast infections (mastitis) including fungal (yeast infection of the nipple or breast) with this baby?*

YesNo

If yes, please list types of medication(s) or treatment(s) and dates used:

19. Did your baby have an in-utero transfusion or transplant?*

YesNo

If yes, date:

20. Has there been any cases of rubella, chickenpox (Varicella), or shingles (Herpes Zoster) in your household during the time you expressed milk?*

YesNo

If yes, please provide date of infection and which family member:

21. Were you ever feeling unwell when you pumped milk?*

YesNo

If yes, what were your symptoms and what medications did you use to treat?

22. Have you taken Amiodarone (for arrhythmia) in the two years prior to the earliest milk you have stored?*

YesNo

EXPOSURES & INFECTIONS

23. Do you have a history of cold sores, genital herpes, lesions on your breast?*

YesNo

If yes, select all that apply:

cold soresgenital herpeslesions on your breast

If applicable to any, list date of last outbreak and any medications used for treatment:

24. Do you or anyone in your household currently have a cough that has lasted longer than 3 weeks?*

YesNo

If yes, please explain:

25. Have you or anyone else in your household been coughing up blood and running a fever?*

YesNo

If yes, please explain:

26. In the last 12 months, have you been exposed to Hepatitis A and/or received a gamma globulin shot?*

YesNo

27. In the last 12 months, have you been close contact with a person with jaundice (yellow skin and eyes) or viral hepatitis, or have been given Hepatitis B Immune Globulin (HBIG) ?*

YesNo

If yes, please explain:

28. Have you had exposure to someone with HIV or AIDS in the last 12 months?*

YesNo

If yes, please explain:

29. Have you ever had tuberculosis, exposure to TB, or a positive TB test or chest x-ray?*

YesNo

If yes, please explain any follow up TB testing including results:

30. In the last 6 months have you or your partner had a blood transfusion or received blood products, or an organ or tissue transplant?*

YesNo

If yes, provide date(s):

31. In the last 6 months have you or your sexual partner(s) had body parts pierced, a tattoo, permanent make-up applied with needles, microblading and microneedling, or acupuncture with non-sterile needles or multiple use dye pots?*

YesNo

32. In the last 6 months, have you or your sexual partner had an accidental needle stick with a contaminated needle, or exposure to someone else’s blood?*

YesNo

If yes, please explain:

33. Have you or your sexual partner tested positive for or been treated for Syphilis, Gonorrhea, or Chlamydia?*

YesNo

If yes, please list treatment dates and the last negative test result date:

34. Have you or your sexual partner(s) been incarcerated for more than 72 hours in the last 12 months?*

YesNo

35. Have you ever had intimate contact with someone who is at risk for HIV, HTLV, or Hepatitis (including anyone with hemophilia)?*

YesNo

If yes, please explain:

36. Have you been exposed to, have symptoms of, or been treated for Monkeypox?*

YesNo

37. Have you or members of your household been to an area of Ebola Virus outbreak in the last 28 days?*

YesNo

38. Have you been in contact with anyone diagnosed or treated for Ebola?*

YesNo

SUBSTANCE USE & EXPOSURES

39. Do you consume alcohol?*

YesNo

If yes, please describe your intake (what are you drinking, how many drinks per sitting, and how often) AND the wait time after consumption before pumping and storing milk:

40. In the last 12 months have you smoked, used tobacco products, e-cigarettes, vapes, hookahs, or chewed nicotine gum, or used a nicotine patch?*

YesNo

If yes, when was the last time you used these products and how long have you been using these products?

41. In the last 12 months, have you or anyone in your home used recreational drugs such as marijuana (topical cannabis products, vaped or smoked, or consumed edible marijuana), cocaine, LSD, ecstasy, or amphetamines?*

YesNo

If yes, what drug was taken and in what time period?

41a. Were the drugs taken by (select all that apply):

mouthnosesmokinginjection

41b. Are you using any of the above at present?

YesNo

41c. What was the approximate date of last use?

42. Within the last 6 months have you or your sexual partner had multiple sexual partners OR sexual contact with someone who has used a needle to inject non-prescription drugs?*

YesNo

VACCINATIONS

43. In the last 12 months have you had any vaccinations, inoculations, or shots?*

YesNo

If yes, please list immunizations and dates:

43a. Did you have any illness or complications due to the vaccination?

YesNo

If yes, please explain:

44. Since giving birth, have you had a vaccine for live typhoid, or yellow fever?*

YesNo

If yes, please list date:

45. In the past 8 weeks, have you received the smallpox vaccination, or have you had close contact with the vaccination site of anyone else?*

YesNo

45a. If you had the smallpox vaccination, has the vaccination scab fallen off your skin by itself?

YesNo

45b. If you have had close contact with the vaccination site of anyone else, have you had any new skin rash or sore since the time of contact?

YesNoN/A

46. In the last 12 months have you had injections for exposure to rabies or received any experimental vaccine?*

YesNo

BABY'S MEDICAL HISTORY

1. Was your baby jaundiced?*

YesNo

If yes, how long did it last?

2. Has your baby ever had oral thrush?*

YesNo

If yes, please list the dates and medications given to both the baby and the mother (if applicable):

3. Has your baby been exposed to any communicable diseases, such as chicken pox, mumps, measles, or whooping cough?*

YesNo

If yes, when and how was the condition treated?

4. Is your baby gaining weight and growing well?*

YesNo

If no, please explain:

5. Is your baby exclusively breastfed?*

YesNo

If no, please explain:

Next form is REQUIRED. Click ‘Continue’ to proceed and complete your submission.

1887 Monterey Road, Suite 110, San Jose, CA 95112 p (408) 998-4550 MothersMilk.org

Donor Packet

DONOR'S MEDICAL HISTORY & LIFESTYLE HABITS