Donor Mother Screening Consent

You're DONOR MOTHER Registration form has been submitted!

STEP 2

 IMPORTANT: Please fill out and sign our
DONOR MOTHER Screening Consent Form and  Donor Mother Preliminary Oral Screening Questions below...

Thank You

DONOR MOTHER
Screening Consent Form

There are some women in the community who MUST NOT donate their milk as it may transmit infections to the infants who receive it. There are others who will be ineligible to donate milk because of a medical condition or lifestyle choices. Before you consent to becoming a Mothers’ Milk Bank Charity donor, we need to ask various health and lifestyle questions to ensure your donated milk is safe for all recipients.


You will be asked these questions and then required to sign the following declaration in the presence of a Mothers’ Milk Bank Charity consultant. It is important that all questions are answered truthfully and to the best of your knowledge. Giving false and misleading information may jeopardise the health and safety of the infants who receive your donation. If you are uncertain about how you should answer any of the questions, please discuss your concerns with your General Practitioner.


All potential human milk donors are tested for HIV 1 & 2, Hepatitis B & C, HTLV I & II,CMV and Syphilis. Should any test show abnormal results the Mothers’ Milk Bank retains the right to refuse your donation and you will be referred to a specialist for further consultation.


If at any stage you do not wish to proceed with your donation, you need only decline.


HUMAN MILK DONOR DECLARATION

In making this declaration I understand that:
 

  • I have voluntarily chosen to donate my breast milk to the Mothers’ Milk Bank Charity

  • I will not be paid for the milk I donate

  • Once donated, my milk becomes the property of the Mothers’ Milk Bank Charity

  • My donated milk will undergo a pasteurisation process and will subsequently be distributed to infants in need

  • My breast milk or data about my breast milk may be used for associated research purposes

  • The recipients may be charged a processing fee, to be determined by and at the discretion of the Mothers’ Milk Bank Charity, for the pasteurised donor milk
     

In making this declaration I understand that:

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  • My infant or a member of my family becomes ill

  • I take any medications or herbal remedies, prescribed or otherwise

  • Family obligations preclude continuous donations

  • I have been exposed to a contagious illness or disease

  • I have any questions about being a donor
     

I understand that all donor information is confidential. I have read all of the information provided regarding the blood tests for potential donors. I give permission for my blood to be tested for the infections HIV 1 & 2, Hepatitis B & C, HTLV I & I,CMVI and Syphilis. I understand that my General Practitioner will be notified if my blood tests results are of medical significance. I will make every effort to ensure that my milk is donated according to the instructions provided. I understand that I am encouraged to discontinue donating milk if, at any time, my participation interferes with my own family’s needs.


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

Signature *

Please sign the form

DONOR MOTHER
Preliminary Oral Screening Questions

Milk Bank donors are screened in a similar manner to blood donors. The Mothers’ Milk Bank Charity needs to know some of your medical history to ensure that it is safe for you to donate and to ensure that your donated milk will be safe for the infants to whom it will be given.

 

Please read and listen carefully to the list of conditions that MAY mean you are ineligible to donate and discuss any queries or concerns with the Mothers’ Milk Bank Charity consultant.

Are you restricted from giving blood for any reason other than low body weight, pregnancy and nursing?
Do you smoke or use tobacco products including nicotine patches and/or gum?
Have you lived in or travelled to Europe between 1980 and 1996 for a total or cumulative period of 6 months
Did you received a blood transfusion during your pregnancy or at the time of delivery?
Have you received pituitary growth hormones, bovine insulin, and a brain covering graft or had intimate contact with someone who has Creutzfeld-Jakob disease?
Have you got a chronic health condition such as HIV, Hepatitis or a history of cancer?
Have you been treated for TB (Tuberculosis) or had a positive serum TB test (blood test)?
Have you injected yourself with drugs not prescribed by a doctor?
Have you had a sexual partner who has injected him/ herself with drugs not prescribed by a doctor?
Are you taking herbal supplements or vitamins containing herbal supplements?
Do you regularly consume more than 2 standard alcoholic drinks per day?
Do you regularly consume more than 750ml of caffeinated or other stimulant drinks per day?
Do you regularly consume more than 2 serves of cocoa or other stimulant containing foods per day?
Are you breast feeding a child older than 12 months of age?

In the last 12 months

Have you had close (cohabitation or intimate) contact with someone with Hepatitis?
Have you had intimate contact with someone who is at risk for AIDS or HIV, including hemophiliacs and IV drugs users?

In the last 6 months

Have you had acupuncture or electrolysis?
Have you had a blood transfusion or received blood products, or had an organ or tissue transplant?
Have you had an ear or body piercing, a tattoo or permanent make-up?
Have you had an accidental needle injury?
Have you received a vaccination for Hepatitis A or B?

The following conditions are temporary disqualifications and expressing for the Milk Bank Charity may resume at the end of the treatment period.

Do you currently have an infection of the breast such as mastitis or a yeast infection of the breast or nipple?
Do you currently have an infection due to the Herpes Simplex Virus (HSV) (i.e. cold sores) or Varicella (i.e. chicken pox or shingles)?
Do you currently have any condition that requires medication?
After reading and hearing these exclusions, do you think you are eligible to donate to the Mothers’ Milk Bank Charity?

Signature *

Please sign the form

You will be emailed a copy of this form.

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