Human Milk Donation Form
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Thank you for your interest in donating your milk. By completing this form, you will be initiating the process to donate your surplus milk to The New York Milk Bank.

Our screening process includes submission of this form, completion of an interview and application, submission of signed consents from your healthcare providers, and a blood test provided at no cost to you. Following approval, your generous milk donation will directly benefit babies in NICUs in the Tri-State area.

Please expect to hear from us within two days of form submission. If you have any questions or concerns, please feel free to contact us directly by calling 212-956-6455, or emailing us at donatemilk@nymilkbank.org.

 

Name
 
 
 
 


Email Address
 
  

Phone Number
 
  
Can we leave a voicemail at this number?


Address
 



State

  
 
Do you speak English? If no, please do not fill out this form.
Call us at 212-956-6455. 
 
Donor Date of Birth
 

Baby Date of Birth
 


Type of Birth
 
 

Is your baby currently living?
 
 
 
Baby Name(s)
 

  

Was your baby born prematurely? (before 37 weeks gestation)
 

Is your baby still in the hospital?
 


Approximately how many ounces do you have to donate?
 
 
What type/brand of containers or bags is your milk stored in?


Are all the containers or bags dated with the day they were pumped?
 
 

Are your hands and pump parts washed prior to each pump session?
Do you sterilize your pump parts daily?
 


After pumping, how long does your milk stay out at room temperature before freezing or refrigerating?
Placing in a cooler with ice packs is considered refrigerating. 
 
 
 
What type of pump are you using to express milk?
 


How long does your milk stay in the refrigerator before freezing?
 
 

What type of freezer is your milk stored in?
 
 
What is the earliest pump date of the milk you plan to donate?
 
  
Have you donated with us before?
 
  

Are you willing to go to a lab to have your blood tested?
 


Describe your weekly intake of caffeine (coffee/tea/cola)
 


Have you had any breast or nipple infections such as mastitis while pumping?
 


Have you taken any herbal supplements, medication to increase your milk supply, or used the herb fenugreek in any form?
 


Have you or your sexual partner been stuck with a contaminated needle within the last 12 months?
 


Have you ever been told you cannot donate milk or blood?
 


Since giving birth, have you consumed any alcohol?
 


How many drinks do you consume in a day or at a time?

How long do you wait after alcohol consumption to pump and SAVE milk?
 
 



Do you smoke tobacco, use nicotine products, marijuana, electronic cigarettes, or chew tobacco?
 
 

Have you received blood products or a transfusion within the last 6 months?
 


Have you spent more than 5 years cumulatively in France or Ireland from 1980-2001?
 



Have you spent 3 months or more in the United Kingdom from 1980-1996?
 
 



Would you consider yourself or your sexual partner at high risk for exposure to HIV or Hepatitis?
 



Since giving birth, what medications have you taken?
Please list all over the counter and prescription medications.
 

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