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Dear:
Thank you for your interest in the Mothers’ Milk Bank. Your milk may save the life of a sick or
premature infant. New donors are always needed to insure a safe and continuous supply of milk to
patients requiring this precious resource.
Enclosed you will find the medical history forms and consent forms needed to become a donor. All
donors must have their primary care physician or Obstetrician and Pediatrician verify your health status.
Once you have collected a minimum of 100 ounces of frozen milk and all forms are completed and sent
back to MMB, we will contact you to make further arrangements.
As a tissue bank licensed by the California State Department of Health Services and a member of the
Human Milk Banking Association of North America we are required to have blood testing done for all
donors. We have agencies throughout California and the U.S. that will do the blood tests. We will make
the arrangements for you to have the blood tests done, once we have received all your forms.
Please feel free to contact us if you have any questions or concerns. Our hours of operation are Monday
through Friday, 9am to 5pm. Our toll free number is: 877-375-6645.
Sincerely,
Donor Coordinator
1887 Monterey Road Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
Donor # (for office use) __________
1. I have voluntarily chosen to donate my breast milk to the Mothers’ Milk Bank. 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 will be charged to the recipient of the milk. My milk or data about my milk may be
used for research purposes.
2. 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 the Mothers’ Milk Bank:
a. if I, my baby, or a member of my household becomes ill
b. when I take any medications or herbal or dietary supplements
c. when family obligations preclude continuing donations
d. when I have any questions about being a donor
e. when I have been exposed to a contagious illness or disease
3. I am aware that once my milk has been donated it becomes the property of the Mothers’ Milk
Bank and cannot be returned to me.
4. I authorize that blood requisition forms and test results shall be sent by e-mail or regular mail to us from your
health care provider and will remain confidential.
5. I understand that a sample of my milk will be tested for bacteria before and after pasteurization.
6. I have read all of the information about HIV and the blood tests done for donors.
7. I agree to have my blood tested as described in Blood Tests for Milk Donors and understand that
I and a health care provider of my choice will be notified if the results are of medical significance.
9. I hereby certify to the best of my knowledge that I understand and have answered all the questions truthfully. I do
not consider myself to be a person at risk for spreading HIV.
10. I understand that acceptance by the San Jose Mothers’ Milk Bank as a donor is in no way an indication that my
milk is safe to share with individuals outside the milk bank process. Milk banks take several steps to assure the safety
of donor milk beyond health screening of the donor. Therefore, it is a misrepresentation to use the Milk Bank
screening process to guarantee the safety of my milk for a recipient if it has not gone through processes similar to
those used by a donor milk bank.
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ____________
11. I understand that protected health information may be used and disclosed to your primary health care provider if
information discovered in the screening process needs further evaluation, treatment or education. I acknowledge I’ve
been given the opportunity to read and review the Department of Health and Human Services Security and Privacy
Administrative Standards in the Federal Register CFR Part 164.506 Mothers’ Milk Bank follows in accordance to
HIPAA and understand I have a right to review this before signing below. I understand I have a right to request how
my information is used, but Mothers’ Milk Bank may disagree with the request restrictions. I have the right to revoke
this authorization and consent, in writing, at any time, however, issues of public health may require disclosure.
This office reserves the right to amend our privacy policy, whether required by law or otherwise, and a revised notice
may be obtained by calling our office or by physically coming into our office.
I authorize this office to leave messages on my answering machine or by e-mail regarding protected health
information: Yes No
12. I authorize the Mothers' Milk Bank to acknowledge my family by using our pictures and stories on
our website and on social media. Yes No
Some patients prefer that other individuals especially family members, be allowed access to their medical
information. In order to comply with strict legal standards, a written release is required to allow another person
access to your medical records.
This release grants permission to individual(s) listed below to: make or confirm appointments, have access to my
medical charts and laboratory findings, and serve as my emergency contact. This permission applies to telephone and
answering machine messages as well as other means of communication and will be in effect unless I notify this
office of any change or revocations.
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor Interview
Donor # (for office use) ___________
Email address:_______________________________________________________________________
Present/Past Occupation_______________________________________________________________
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ____________
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Name: ________________________________________________________________________
Address: ______________________________________________________________________
* required field
How did you hear about the Mothers’ Milk Bank? _____________________________________
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ____________
Are you donating milk collected before you contacted the milk bank? Yes No
If yes, were you, the baby, and other members of your household healthy during the time you collected
Did you take any medications, over-the-counter or prescription, vitamins or herbal supplements while
pumping? Yes No
If yes, list what you were taking and the dosages, as well as the dates you took them:
_____________________________________________________________________________
____inside refrigerator
____deep freeze
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ____________
Please explain in detail any “yes” responses. Answering “yes” to a question does not necessarily exclude
you as a donor.
1. Have you taken Soriatane (acitretin), and/or Tegison (etretinate) in the last 3 years? Yes No
__________________________________________________________________________
2. Have you taken Proscar (finateride) or Accutane (isotretinoin) during childbearing years?
Yes No If yes, please list dates: ________________________________________
3. If you are donating previously pumped milk, please list any medications or herbal remedies taken
in the week prior to or during the period the milk was expressed.
______________________________________________________________________________
4. Do you smoke, use tobacco, chew nicotine gum, or wear a nicotine patch? Yes No
______________________________________________________________________________
5. In the past 5 years, have you ever used recreational drugs such as marijuana, cocaine, LSD,
b. Were the drugs taken by mouth, nose, smoking or injection? (please circle all that apply)
6. Do you consume alcohol? Yes No If yes, Please describe your intake (how much and how
and how often) and wait time before pumping and storing milk: _________________________________
_____________________________________________________________________________
7. Please describe your daily intake of caffeine: Greater than 24 oz? Yes _____ozs No
8. During this pregnancy, delivery and post-partum period did you have any complications, such as
infection, excessive bleeding, or high blood pressure? Yes No. If yes, please explain, including
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ____________
9. Have you expressed and stored milk before contacting the milk bank or with a previous baby? Yes No
11. Have you had any breast infections with this baby? Yes No If yes, please list types of
12. Are you on any special diet? (e.g. vegetarian, low salt, low calorie, diabetic, dairy-free, etc.)
13. If you are vegan are you supplementing your diet with Vitamin B12 daily? Yes No N/A
Names: Ages:
____________________________________________________ _______
____________________________________________________ _______
____________________________________________________ _______
____________________________________________________ _______
15. In the last 12 months have you had surgery or been under a doctor’s care for a major illness?
Yes No If yes, please explain. List any medications used and dates of use.
_____________________________________________________________________________
16. Have you ever been told not to donate blood or milk? Yes No If yes, please explain:
______________________________________________________________________________
17. Have you had jaundice, liver disease, or hepatitis? Yes No If yes, please explain:
___________________________________________________________________________
18. In the last 12 months, have you been exposed to Hepatitis A and/or received a gamma globulin
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ___________
19. In the last 12 months have you had close contact with a person with jaundice or viral hepatitis or
have you been given Hepatitis B Immune Globulin (HBIG)? Yes No
If yes, please explain: _________________________________________________________________
20. Have you had exposure to someone with HIV or AIDS in the last 12 months? Yes No
21. In the last 12 months have you or your sexual partner(s) had ears or body parts pierced, a tattoo,
permanent make-up applied with needles, or acupuncture with non-sterile needles? Yes No
22. Since giving birth did you or your partner get a tattoo in a regulated/licensed site using sterile
23. Have you had an accidental needle stick, or exposure to someone else’s blood? Yes No
24. Have you ever had tuberculosis, exposure to TB, or a positive TB test or chest x-ray? Yes No
Please explain any follow-up TB testing including results:___________________________________________
25. Have you ever been treated for TB? Yes No
If yes, please list treatment and date(s): __________________________________________________________
26. Do you or anyone in your household currently have a cough that has lasted longer than 3 weeks? Yes No
27. Have you or anyone in your household been coughing up blood and running a fever? Yes No
28. Have you ever had heart disease or high blood pressure? Yes No If yes, please explain, list any
medications and dates: ______________________________________________________________________
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use)____________
30. In the last 12 months have you tested positive for or been treated for Syphilis, Gonorrhea,or Chlamydia?
31. Do you have a history of oral or genital Herpes? Yes No If yes, date of last outbreak:_____________
32. Do you have cold sores? Yes No If yes, how often and date of last outbreak: _______________________
33. Since giving birth, have you had a vaccine for measles, mumps or rubella? Yes No
If yes, please list date: ______________
34. Has there been any cases of rubella or chickenpox in your household since giving birth? Yes No
35. Since giving birth, have you had a vaccine for chickenpox, rotavirus or yellow fever? Yes No
If yes, please list date: ______________
36. Have you had a skin disease or unexplained skin lesions? Yes No
37. In the last 12 months have you had any vaccinations, inoculations, or shots? Yes No
38. Did you have any illness or complication due to the vaccination? Yes No.
If yes, please explain: _____________________________________________________________________.
39. Since giving birth, have you received the smallpox vaccination, or have you had a close contact
a) If you had the smallpox vaccination, has the vaccination scab fallen off your skin by itself? Yes No
b) If you have had close contact with the vaccination site of anyone else, have you had any new skin
rash or sore since the time of contact? Yes No
40. In the last 12 months have you had injections for exposure to rabies or received any experimental vaccine?
Yes No
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use)____________
41. Do you have a history of yeast infections (oral, vaginal or systemic) or unexplained white sores or
lesions in the mouth? Yes No If yes, please explain, include medication and dates:
___________________________________________________________________________________
42. Do you have or have you had unexplained weight loss, persistent diarrhea, fever, or night sweats?
Yes No
43. Do you have or have you had unexplained enlarged lymph nodes? Yes No
44. In the last 12 months have you received blood, blood products, or an organ or tissue transplant?
Yes No
45. Have you ever received human pituitary growth hormone, bovine insulin, or a dura mater
(brain covering) graft? Yes No
48. Did you live 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? Yes No
49. Since 1980, have you received any blood or blood component transfusions in the UK? Yes No
50. Since 1980, have you spent time in Europe that adds up to a total of 5 years or more? (Includes
Albania, Austria, Belgium, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark,
Finland, France, Germany, Greece, Hungary, Ireland, Italy, Liechtenstein, Luxembourg,
Macedonia, Netherlands, Norway, Poland, Portugal, Romania, Slovak Republic, Slovenia, Spain,
Sweden, Switzerland, United Kingdom, and Federal Republic of Yugoslavia) Yes No
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) __________
51. Between 1980 and 1996, were you a member of US Military, a civilian military employee or a
If yes, did you spend a total of 6 months or more associated with a military base in any of the following countries:
From 1980 through 1990 in Belgium, the Netherlands, UK, or Germany Yes No
From 1980 through 1996 in Spain, Portugal, Turkey, Italy, or Greece Yes No
52. Have you ever had intimate contact with someone who is at risk for HIV, HTLV or Hepatitis (including anyone
53. Did your baby have an in utero transfusion or transplant? Yes No If yes, date? _______________
54. Have you or your sexual partner(s) been incarcerated for more than 72 hours in the last 12
55. Have you traveled to Africa in the past month? ( at least 28 days) Yes No
56. Have you been intimate with someone who traveled to Africa in the past month?
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ___________
1. Was your baby jaundiced? Yes No If yes, how long did it last? ________________________
2. Has your baby ever had a yeast infection (i.e. thrush or diaper rash linked to a yeast infection)? Yes No
If yes, list dates and medications:______________________________________________________________
3. Has your baby been exposed to any communicable diseases, such as chicken pox or mumps?
4. Does your baby have frequent infections, such as colds, ear infections, diaper rash, or skin infections?
5. Is your baby gaining weight and growing well? Yes No If no, please explain:
________________________________________________________________________________
_________________________________________________________________________________
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) _____________
Date: __________________________
Baby’s name: ___________________ Baby’s Date of Birth: ____________ Medical Record #____________
_________________________________ _____________________________
Donor Mother’s Name (print) Donor Mother’s Signature
Please complete the following information and either fax or mail it back to us at 1(408)297-9208. Please call us at
1(408)998-4550 if you have any questions or concerns. All donor records are confidential.
I am aware of no adverse effect for the health of baby ___________________________ if the mother
______________________________________
Provider Signature and Date
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ___________
Medical Information Regarding Donor Mother
Date: __________________________
requested medical information to the Mothers’ Milk Bank. I acknowledge that I can refuse to sign this
Your patient has volunteered to donate milk to the Mothers’ Milk Bank. Please complete the following
information and either mail or fax it back to us at 408-297-9208. If these tests have not been done no
more than 6 months prior to the first donation, we will do them at no cost to the donor before she begins
donating milk. Please call us at 408-998-4550 if you have any questions or concerns. All donor records
are confidential. Thank you for your assistance.
Information Required From Health Care Provider
To the best of your knowledge, does this patient have a history of:
______________________________________ __________________________
Provider Signature Date
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018
Donor # (for office use) ____________
The HIV test detects antibodies to the HIV (AIDS) virus. At this point, it is reasonable not
to accept milk from anyone who has ever been exposed to the virus.
While the test for antibodies to the HIV (AIDS) detects almost everyone who carries the
antibody to the virus, it occasionally is falsely positive.
Other viruses screened for are: Hepatitis B, Hepatitis C, HTLV-I and Syphilis. If donor
shows of any of these viruses (including a false reaction on any test), we will not be able to
use your milk.
If any of these tests are reactive, the health care provider named on your screening form
will be notified to discuss the confidential results with you. These results, if reactive, are
reportable to the State Department of Health.
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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
www.mothersmilk.org
Member of the Human Milk Bank Association of North America
Non profit #77-0131926
REV 1.2.2018