Donor Interview

Name

Age

Date of Birth

Phone:

home

work

cell

Does the milk bank have permission to leave a message on your voice mail, answering machine or with a person answering one of the above numbers?

Yes

E-Mail (for communication only):

Address

Apt.

City

State

Zip

Past/present occupations(s)

Partner’s Name:

Partner’s Occupation/Company

Baby’s Name

Sex

Male Female

Age

Birth Date

Birth Weight

Birth Height

Last Weight

Last Height

Date

Was baby full term?

Yes No

Is baby at:

Home Hospital

*Please provide phone and fax numbers if possible, Thank you!

Mother’s Health Care Provider (OB doctor or Midwife)

Name

Phone ^*

Address

Fax ^*

City

State

Zip

Baby’s Health Care Provider (Pediatrician, Family Doctor, Nurse Practitioner):

Name

Phone ^*

Address

Fax ^*

City

State

Zip

DONOR CONSENT FORM

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 the milk may be used for research purposes.
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:
1. if I, my baby, or a member of my household become ill
2. when I need to take any medications
3. when family obligations preclude continuing donations
4. when I have any questions about being a donor
5. when I have been exposed to a contagious illness or disease
I am also aware that once my milk has been donated it becomes the property of the Mothers’ Milk Bank and may be shared with another non-profit milk bank if there is a critical need.
I have read and understand the Notice of Privacy Practices provided by MMBM and I understand that all donor information is confidential.
I hereby certify to the best of my knowledge that I understand and have answered all the questions truthfully. I have reviewed and understand the information provided to me regarding the spread of HIV. I do not consider myself to be a person at risk for spreading HIV.
I have read all of the information about HIV and the blood tests done for donors.
I agree to have my blood tested as described in Blood Tests for Milk Donors and understand that I will be notified if the results are of medical significance.
I understand that I am encouraged to discontinue donating milk anytime my participation interferes with my own family’s needs.
MMBM [ maymay not ] use my name or picture with prior notification for the purpose of promoting the service of the milk bank, in a newsletter published by the milk bank, or on social media.
I understand that if I send photographs or cards to MMBM they may be posted on the bulletin board or online, including website, social media, email, or newsletter.

Donor Signature

Date:

MEDICAL INFORMATION REGARDING DONOR MOTHER

The information in this form will be completed by your healhcare provider. Please sign below to authorize.

Instructions for the Health Care Provider:

Your patient has volunteered to donate milk to the Mothers’ Milk Bank of Mississippi. Please complete the following and either mail or fax back to us at (601)939-6555. Please call us at (60)-939-5504 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:
(TO BE COMPLETED BY HEALTH CARE PROVIDER)

1. genital herpes?

Yes No

2. blood transfusion in the last 12 months?

Yes No

3. TB, hepatitis or prenatal viral infection?

Yes No

4. taking any medication on a regular basis?

Yes No

List medications

Please report test results below:

	Results	Date
1. RPR
2. Rubella
3. HIV-I & II
4. HTLV I & II
5. HbsAg
6. Hepatitis C

To the best of my knowledge, ___ is in good health and would be an appropriate donor to the milk bank.

Health Care Provider Signature

Date

Donor's Consent to Release Donor Mother's Health Records

I authorize Dr. to release the requested medical information to the Mothers’ Milk Bank of Mississippi.

Donor’s Name

Date of Birth

Donor Signature

Date: