Donor Registration & Screening Form

DONOR MOTHER
Screening Consent Form
Registering to become a Donor Mother is a 2 STEP process.
STEP 1
Please fill out the Donor Registration & Screening form below and SUBMIT
STEP 2 - Blood Tests
To donate we need your donor screened blood results.
Please call your GP to order the blood test, they will bulk bill. Ask your GP for the blood test needed to donate & to give you a copy of the results.
TEST FOR :
Hep B & Hep C, HIV, Syphilis, HTLV 1 & 2, CMV
You will be emailed with more detailed information once STEP 1 is submitted.

Thank You

Thank you for offering to donate your breast milk. This will help parents and carers with babies in need of breast milk make a healthy start to life.  To confirm your donor milk is safe for other babies, some of whom are particularly vulnerable, we ask you to undertake some standard blood tests and to answer the following questions. If you are unsure about any of the question, please speak to your doctor.

1. I wish to become an ongoing donor to Mothers’ Milk Bank
2. Is this a one of donation of milk?
6. Did you have a blood transfusion during your pregnancy or at the time of your birth?
7. Are you restricted from giving blood for any reason?
8 . Have you had an organ or tissue transplant?
9. From 1 January 1980 through to 31 December 1996 inclusively, have you spent (visited or lived) for more than 6 months in the United Kingdom?
10. Do you have any chronic health conditions such as HIV, Hepatitis or have a history of cancer?
11. Have you been treated for TB (Tuberculosis) or had a positive serum TB test (blood test)?
13. Have you had close or intimate contact with someone with Hepatitis, AIDS, HIV or IV drug users?
14. In the last 12 months have you had electrolysis, acupuncture, tattoo or accidental needle stick injury?
15. Have you received a vaccination for Hepatitis A or B?

We cannot accept your donor breast milk if you:

a. Drink more than 2 standard alcoholic drinks per day.

b. Consume more than 750mls of caffeinated or stimulant drinks daily.

c. Eat a lot of chocolate or stimulant foods daily.

b. Smoke, vape or use nicotine patches and/or gum.

c. Have used recreational drugs in the last 12 months.

 

If you have or have had a recent breast or nipple infection or, any infection, you MUST wait 7 days after finishing the last medication or treatment before expressing and collecting your milk for the Milk Bank.

 

You must wait 7 days following a reactivation of a latent infection with herpes simplex virus (cold sore) or varicella zoster (shingles) of the breast or chest starting from when the lesions crust over.

16. After reading these exclusions, do you think you are eligible to donate to the Charity?

Additional Questions:

One of the most important tasks of Mothers’ Milk Bank is to support mothers who have difficulties breastfeeding their baby.

 

Answering any of the questions below is entirely voluntary and not mandated by the existing guidelines.

The reason for these questions is that we are trying to understand whether there are certain factors or that mothers who can successfully breastfeed and are also able to donate might have in common. This might help us to improve our advice/support to mothers who have insufficient breast milk. All answers  are anonymous.

6. What is your diet?

I understand that:

 

  • If I change my medications or commence some or any herbal remedies, prescribed or otherwise I will contact the Charity.

  • I will contact the Charity if I become sick or am exposed to any contagious condition that temporarily or permanently may stop me from donating milk to the Charity.

  • I have donated my milk without payment and it becomes the property of the Charity.

  • My data will be kept private and this and or my milk maybe used for research purposes.

  • Recipients maybe charged a processing fee at the discretion of the Charity.

  • I may change my mind at anytime and choose not to proceed with my donation.

 

I, hereby, certify that I have understood and answered all questions truthfully.

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You will be emailed a copy of this form.