1. I have voluntarily chosen to donate my breast milk to Mothers' Milk Bank at Austin. 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 may be charged to the recipient of the milk.

    

2. My milk may be used for research purposes, when the research is expected to benefit recipients of human milk. If intended use is for research, I will be informed.

    

3. 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 Mothers' Milk Bank at Austin:

    

   • in the case of illness involving fever or medications

      

   • when I need to take any new medications or herbal or dietary supplements;

      

   • when family obligations preclude continuing donations;

      

   • when I have any questions about being a donor;

      

   • when I have been exposed to a contagious illness or disease.

      

4. I am aware that once my milk has been donated it becomes the property of Mothers' Milk Bank at Austin and cannot be returned to me.

    

5. I understand that a sample of my milk will be tested by a microbiology lab both before and after pasteurization.

    

6. I understand that a sample of my milk will be tested for nutritional values; specifically protein, fat, and carbohydrates.

    

7. I understand that all donor information is confidential and I have read the Privacy Statement provided by Mothers' Milk Bank at Austin.

    

8. I have read all of the information about HIV and the blood tests done for donors.

    

9. I agree to have my blood tested as described in “Blood Testing FAQs” and understand that I will be notified of the results. 

    

10. I hereby certify, to the best of my knowledge, that I understand and have answered all the questions truthfully.

     

11. I understand that I must be notified of approval before donating milk, and that approval does not indicate that my milk is safe to share/sell informally.

     

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1.  Yes  No  Are you donating milk that is already expressed and pumped?

    

   1.  Yes  No If yes, has the milk you are donating been heated or thawed in any way? If yes, please explain:
      

       

   2. How long is your milk refrigerated before going into the freezer?

       

   3.  Yes  No Were you and other members of your household healthy during the time you collected this milk? If no, please explain:
      

       

2.  Yes  No  Are you under a physician's care for anything, acute or chronic? If yes, please explain:
   

    

3.  Yes  No  Have you taken any Prescription Medications at any time since your pregnancy ended? Please include anything you are currently taking, as well as anything you took since giving birth. Please list the names of all prescription meds as well as dates taken:

    

4.  Yes  No  Have you taken any over-the-counter medications at any time since your pregnancy ended? Please include anything you are currently taking, as well as anything you took since giving birth. Please list the names of all over the counter meds as well as dates taken:

    

5.  Yes  No  Have you taken any vitamins, dietary or herbal supplements at any time since your pregnancy ended? Please include anything you are currently taking, as well as anything you took since giving birth. Please list the names of all vitamins, dietary, or herbal supplements as well as dates taken:

    

1.  Yes  No   Have you had any complications such as infection, excessive bleeding or high blood pressure during this pregnancy, delivery, or postpartum period? If yes, what was the diagnosis and treatment? Is there any ongoing treatment?
   

    

2.  Yes  No   Have you had any breast infections while pregnant or expressing milk? If yes, please give dates and describe what medications were needed and all the dates you took the medications:
   

    

3.  Yes  No   Have you taken Accutane or Amiodarone in the last 2 years?

    

4.  Yes  No   Have you or a sexual partner used drugs in the last 12 months for recreational or medicinal purposes, such as marijuana in any form (including edibles), cocaine, LSD, ecstasy, amphetamines or any illegal medications ?

    

   •   If yes, what drugs were taken and when?
     

      

5.  Yes  No   Have you used any CBD products since the pregnancy ended?

    

   •   If yes, when was the last date of use: 

      

6.  Yes  No   Have you had surgery or been under a doctor's care for anything other than pregnancy in the past 12 months? If yes, please explain:
   

    

7.  Yes  No   Have you ever been told not to donate blood or milk? If so, why:
   

    

8.  Yes  No   Have you ever had jaundice (excluding immediately after birth), liver disease or any type of hepatitis?

    

9.  Yes  No   Have you had close contact with a person with jaundice or viral hepatitis, or been given Hepatitis B Immune Globulin (HBIG) in past 12 months? If yes, please explain: 

    

10.  Yes  No   Have you or a sexual partner been exposed to Ebola in the past month?

     

11.  Yes  No   Have you had exposure to someone with HIV or AIDS in the past 12 months? If yes, please explain:
    

     

12.  Yes  No   Have you or a sexual partner gotten a piercing, tattoo, permanent make-up, acupuncture, microblading, dry needling, or electrolysis from a unlicensed site in the last 12 months? If yes, please explain:
    

     

13.  Yes  No   Have you or a sexual partner had an accidental needle stick with a contaminated needle in the last 12 months? If yes, please explain:
    

     

14.  Yes  No   Have you had an outbreak of herpes simplex virus or shingles in the last 12 months? If yes, when?

     

15.  Yes  No   Have you ever had Tuberculosis, a positive TB test, or a positive chest X-ray? If yes, did you have any of the following?

     

    •  Yes  No   Medication for TB for 6 months

       

    •  Yes  No   Negative chest X-ray

       

    •  Yes  No   Both

       

16.  Yes  No   Have you tested positive for or been treated for Syphilis, Gonorrhea or Chlamydia in the last 12 months?

     

17. List any vaccines or shots you have had in the last 12 months:

     

    •  Yes  No   Polio? If yes, when? 

       

    •  Yes  No   MMR (Measles, Mumps, Rubella)? If yes, when? 

       

    •  Yes  No   Chicken Pox?  If yes, when? 

       

    •  Yes  No   Typhoid? If yes, when? 

       

    •  Yes  No  Other Please explain and provide the date: 

       

18.  Yes  No   Have you received a smallpox vaccine or had close contact with the vaccination site of anyone else in the past 8 weeks?  If yes:

     

    •  Yes  No   If you had the smallpox vaccine, has the scab fallen off your skin by itself?

       

    •  Yes  No   If you had close contact with the vaccination site of anyone else, have you had any new skin rash or sore since the time of that contact?

       

19.  Yes  No   Has anyone in your household had chicken pox in the last month?

     

20.  Yes  No   Have you or a sexual partner received blood, blood products, organ or tissue donations in the past 12 months (excluding Rhogam)?

     

21.  Yes  No   Have you ever received a dura mater (brain covering) graft?

     

22.  Yes  No   Have you ever been diagnosed with Creutzfeldt-Jakob Disease (also called "Mad Cow DIsease") or any other form of transmissible spongiform encephalopathy (TSE)?

     

23.  Yes  No  Have you ever been diagnosed with cancer? If yes, what kind and in what year? Please note if treatment is ongoing.
    

     

24.  Yes  No   In the last 12 months, have you had sexual contact with someone who is at risk for HIV, HTLV, or hepatitis (including anyone with hemophilia)?

     

25.  Yes  No   Have you or a sexual partner been incarcerated for more than 72 hours in the last 12 months (including lock-up, jail, or prison)?

     

26.  Yes  No   Do you smoke or use tobacco products, chew nicotine gum, wear a nicotine patch, vape or use an electronic cigarette?

     

27.  Yes  No   Do you drink alcohol? If yes:

     

    • How often: 

       

    • How many servings at a time: 

       

    • How long do you usually wait between drinking and pumping?

       

    •  Yes  No   Going forward, can you commit to waiting 6 hours after each serving of alcohol before pumping for donation?

       

28.  Yes  No   Do you follow a vegan diet?

     

    •  Yes  No If yes, do you supplement with vitamin B12?

       

29.  Yes  No   Are you currently feeling well? If no, please explain: 
    

     

1.  Yes  No   Have you lived in the United Kingdom (including England, Ireland, Scotland, Wales, The Isle of Man, The Channel Islands, Gibraltar or the Falkland Islands) for more than 3 months between 1980 and 1996?

    

2.  Yes  No   Have you received a blood or blood component transfusions in the UK, Ireland, or France since 1980? 

    

3.  Yes  No   Between 1980 and 2001, have you spent time that adds up to 5 years or more in Ireland or France (not including French overseas departments: Martinique, French  Guiana, Guadeloupe, Mayotte, and Réunion)?

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