Name of the MMBA employee who did your phone interview:
(please choose)
Alison
Jessica
Jen
Other
Donor ID #
*please note:This form is quite long. If you need to save your progress to complete the form at a later time, use the button below.
Confidential Donor Interview
Donor Consent
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.
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.
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 in myself, or my baby;
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.
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.
I understand that a sample of my milk will be tested by a microbiology lab both before and after pasteurization.
I understand that a sample of my milk will be tested for nutritional values; specifically protein, fat, and carbohydrates.
I understand that all donor information is confidential and I have read the Privacy Statement provided by Mothers' Milk Bank at Austin.
I understand that a minimum initial milk donation of 100 ounces (200 ounces for shipping donors) is expected and continued pumping and donating (any amount) is encouraged for up to one year postpartum.
I have read all of the information about HIV and the blood tests done for donors.
I agree to have my blood tested as required and understand that I will be notified of the results.
I hereby certify, to the best of my knowledge, that I understand and have answered all the questions truthfully.
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.
Donor Name:
Please sign with finger or mouse below:
Clear Signature
Demographic Information
The following questions are asked only to help us to understand who serve as milk donors.
Race and ethnicity:
White or Caucasian
Hispanic or Latino
Black or African American
Asian or Pacific Islander
Native American or Alaska Native
Other
:
I prefer not to answer
Annual household income:
under $10,000
$10,000 - $19,999
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 - $89,999
$90,000 - $149,999
$150,000 +
I prefer not to answer
Highest level of education completed:
8th grade or below
Some High School
High School Graduate
Some College
Trade, Technical, or Vocational Training
Associate Degree
Bachelor's Degree
Masters Degree
Professional Degree
Doctorate
I prefer not to answer
Donor Information
First Name:
Last Name:
Cell Phone:
Alternate Phone (optional):
Birth Date:
Address:
Address:
City:
State:
AA
AE
AK
AL
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WV
WI
WY
Zip:
Email address:
Partner's Name:
Past / Present Occupation:
Do you plan to return to work?
Yes
No
If yes, when?
Dept of Defense # (if applicable)
Yes
No
Does Mothers' Milk Bank at Austin have permission to leave a message on your voicemail, or with the person answering one of the above numbers?
We appreciate your generosity during this time of loss. If you would like us to honor your baby, please share the name you would like us to use.
Donor OB-GYN or Midwife Contact Information:
*please provide phone and fax numbers to facilitate faster approval
Provider First Name:
Provider Last Name:
Clinic Name:
Phone:
Fax:
Address:
Address:
City:
State:
AA
AE
AK
AL
AP
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WV
WI
WY
Zip:
Milk Collection Information
Yes
No
Are you donating milk that is already expressed and pumped?
Yes
No
If you are donating milk that is already expressed and pumped, h
as the milk been frozen and then thawed in any way? If yes, please explain:
How long is your milk refrigerated before going into the freezer?
Yes
No
Were you and other members of your household feeling well during the time you collected this milk? If no, please explain:
Donor Medical History and Health Habits
For the following questions, please provide additional details where necessary. Your response to a question will not necessarily exclude you as a donor.
Yes
No
Are you currently feeling well? If no, please explain:
Yes
No
Have you had any complications such as infection, excessive bleeding, or high blood pressure during this pregnancy, delivery, or post partum period? If yes, what was the diagnosis and treatment? Is there any ongoing treatment?:
Yes
No
Have you had any breast infections since delivery? If yes, please give dates and describe what medications were needed and what dates you took the medications:
Yes
No
Are you under a physician's care for anything, acute or chronic? If yes, please explain and include any medications or treatments:
Yes
No
Have you had surgery or been under a doctor's care for anything other than pregnancy in the last 12 months? If yes, please explain:
Yes
No
Have you ever been diagnosed with cancer? If yes, what kind and in what year? Please note if your treatment is ongoing.
Yes
No
Have you taken any
Prescription Medications
at any time since the baby's birth? Please include anything you are currently taking, as well as anything you have taken since your baby's birth. Please list the names of all prescription meds as well as dates taken:
Yes
No
Have you taken any
Over-the-Counter (OTC) medications
at any time since the baby's birth? Please include anything you are currently taking, as well as anything you have taken since your baby's birth. Please list the names of all OTC meds as well as dates taken:
Yes
No
Have you taken any
vitamins, minerals, or supplements (dietary, herbal, or otherwise)
at any time since delivery? Please include anything you are currently taking, as well as anything you have taken since your baby's birth. Please list the names of all vitamins, minerals, or supplements, as well as dates taken:
Yes
No
Have you taken Accutane or Amiodarone in the last two years?
Yes
No
Have you been vaccinated for COVID-19? If yes, please provide vaccine manufacturer and month/year of each round received (if known).
Yes
No
Have you been exposed to anyone with chicken pox in the last month? If yes, explain:
Yes
No
Do you drink alcohol? If yes:
How often:
How many servings at a time:
How long do you usually wait to pump and store milk after drinking?
Yes
No
Going forward, can you commit to waiting 6 hours after 1 serving of alcohol, and 12 hours after more than 1 serving of alcohol before pumping and storing for donation?
Yes
No
Have you used any CBD products since giving birth? If yes, when was the last date of use?
Yes
No
Do you smoke, use tobacco products, chew nicotine gum, wear a nicotine patch, vape, or use an electronic cigarette or hookah(water pipe)?
Yes
No
In the past 12 months, have you used drugs for recreational or medicinal purposes, including marijuana in any form (including edibles), cocaine, LSD, ecstasy, amphetamines, or any illegal medications? If yes, which drugs were taken and when?
Yes
No
Have you ever been told not to donate blood or milk? If so, why?
Yes
No
Have you ever had jaundice (excluding immediately after birth), liver disease, or any type of hepatitis?
Yes
No
Have you had close contact with a person with jaundice (other than your own baby), Hepatitis B or Hepatitis C, or been given Hepatitis B Immune Globulin (HBIG) in the past 12 months? If yes, please explain:
Yes
No
In the past 12 months, have you or a sexual partner used non-prescription injectable drugs? If yes, please explain:
Yes
No
In the past 3 months, have you had sexual contact with someone who has HIV or AIDS or has been exposed to HIV or AIDS through sexual contact? If yes, please explain:
Yes
No
In the past 3 months, have you had sexual contact with someone who has had sexual contact with another person? If yes, please explain:
Yes
No
In the past 3 months, have you had a new sexual partner, or had sexual contact with someone who has had a new sexual partner in the last 3 months?
Yes
No
In the past 3 months, have you had sex with a man who has had sex with another man in the past 3 months?
Yes
No
In the past 3 months, have you or a sexual partner exchanged sex for money or drugs? If yes, please explain:
Yes
No
Have you had an accidental needle stick with a contaminated needle in the last 3 months or been exposed to another person's blood in any way? If yes, please explain:
Yes
No
Have you had an outbreak of herpes simplex virus or shingles in the past 2 months? If yes, please explain:
Yes
No
In the past 3 months, have you tested positive or been treated for a sexually transmitted illness such as Syphilis, Gonorrhea, or Chlamydia?
Yes
No
Have you been exposed to Ebola Virus in the past 2 months?
Yes
No
In the past 3 months, have you gotten a piercing, tattoo, permanent makeup, acupuncture, microblading, dry needling, or electrolysis at an unlicensed site? If yes, please explain:
Yes
No
In the past 3 months, have you received organ or tissue donations, blood, or blood products (excluding Rhogam)? If yes, please explain:
Yes
No
Have you ever had brain surgery? If yes, have you ever received a human dura mater graft?
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)?
Yes
No
Have you been incarcerated for more than 72 hours in the last 12 months (including lock-up, jail, or prison)?
Release of Medical Information for Donor
I
(donor name) authorize
(midwife or OBGYN name) to release the requested medical information to Mothers' Milk Bank at Austin. I acknowledge that I can refuse to sign this document and that I can have a copy of it by request.
The following information will be requested from your heath care provider:
Any complications during pregnancy, labor and delivery, or the postnatal period.
Medications or supplements you have taken since delivery.
Reports from the following tests with dates (if applicable): RPR, HbsAg, HTLV 1&2, HIV 1/11/0, Hepatitis C
Immune Status for Rubella and/or date MMR was given
Certification that you are in good health.
Please sign with finger or mouse below:
Clear Signature
click here to submit form securely!