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.

2. I wish to become an ongoing donor
1. Is this a one off 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 inclusivley, 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 or TB (Tuberculosis) or had a positive serum TB test (blood test)
12. Have you had close or intimate contact with someone with Hepatitis, AIDS, HIV or IV drug users?
13. In the last 12 months have you had electrolysis, acupuncture, tattoing or accidental needle stick?
14. Have you received a vaccination for Hepatitus 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 had a recent breast or nipple infection, or any infection, you MUST wait 7 days after finishing the last dose of medication or treatment before expressing and collecting your milk for MMBC.

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 before expressing and collecting your milk for MMBC.

17. After reading these exclusions, do you thinkyou are eligible to donate to MMBC?

Additional Questions:

One of the most important tasks of Mothers’ Milk Bank Charity is to support mothers who have difficulties breast feeding their baby/ies.

 

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

 

All answers are de-identified to ensure they remain anonymous.All answers provided are used for research purposes only and will assist MMBC to improve our advice/support to mothers who have insufficient breast milk supplies.

 

We thank you for taking the time to answer these questions and donating your breast milk to mothers and babies in need.

5. Were you breastfed yourself?
6. Are you vegetarian
7. Are you vegan?

The following questions are about your general diet. Please, estimate the amounts or frequency of food intake based on the last 6 -12 months.

15. Do you eat cereals?
16. Do you take nutritional supplements?
17. Are you lactose intolerant or do you consume a lactose/dairy free diet?
18. Are you Coeliac or o you consume a gluten free diet?

I understand that:

 

  • If I change my medications or commence taking any herbal remedies, prescribed or otherwise, I will notify MMBC.

  • I will contact MMBC if I become unwell with a contagious or serious medical condition that may temporarily or permanently stop me from donating milk to MMBC.

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

  • My data and milk will be kept private and may be used for research purposes.

  • Recipients may be charged a processing fee at the discretion of MMBC.

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

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