Milk Donor Form – Sask Milk Bank

Mother
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Previous milk donor?*
Email*
Enter Email Confirm Email
Mobile Phone
Home Phone
Address*
Street Address Address Line 2 City Province Postal Code
GP/Doctor
Hospital Number

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Seriological Screening
Date Blood Taken
MM slash DD slash YYYY
Date Samples Received
MM slash DD slash YYYY
Date Results Received
MM slash DD slash YYYY
Results
Check any result that came back positive.
- Hepatitis B
- Hepatitis C
- Syphilis
- HIV 1 or 2
- HTLV 1 or 2

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Baby
Name*
Age at Enrolment (Weeks)*
Please enter a number from 1 to 99.
Date of Birth*
MM slash DD slash YYYY
Place of Birth*
Admitted to ICU?*
Reason for admission to ICU:*
Birth Weight*
Gestation Age*
List all other children:
Click the (+) button to add another child.
Name Age

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PART A
Mother's Questionnaire
Do you smoke or use nicotine replacement therapy?*
Do you use recreational drugs, or have you used any recently?*
Have you ever tested positive for HIV1 or 2, hepatitis B or C, Human T-lymphotrophic virus [HTLV], or syphilis?*
Are you at an increased risk of Creuzfeldt-Jacob disease [CJD]?*
Have you had any surgery involving a skin, bone, or tissue graft; ever received Human Pituitary Extract; or received any blood transfusion or blood products since 1980?
How often do you consume alcohol?*
*You MUST wait at least 12 hours after consuming alcohol before pumping and storing breast milk. If you are considering being a donor, try to keep a log of any alcohol consumption dates.
Comments for Part A
If you have answered YES to any of the questions above, you will NOT be able to donate milk.
PART B
Questions about your health
Have you had any illnesses in the past year?*
Do you have any diagnosed medical conditions?*
Please describe any medical conditions you have:*
Are you currently taking any medication? Were you taking any medication whilst expressing milk?*
Have you had any fertility treatment?*
Are you taking any herbal medication/remedies, or were you taking any whilst expressing milk?*
Do you live with a smoker, or are you exposed to a lot of passive smoke?*
Have you been exposed to any significant environmental or chemical contaminants?*
Comments for Part B
PART C
Questions about your baby
Has your baby had any prior illnesses?*
Please describe any illnesses your baby has had:*
Are there any concerns about your baby’s weight?*
Are you still exclusively breastfeeding your baby?*
Comments for Part C
PART D
Expressing and storage of milk
Do you have a 3 star freezer?*
How are you collecting your expressed breast milk?*

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Thank you for answering these questions!
As with blood donors, we need to ensure that all milk donors have tested negative to Human Immunodeficiency Virus (HIV), Hepatitis C & B, HTLV 1 & 2, and Syphilis. These tests are required to be taken at the time you would like to register to donate your milk. Please talk to the Milk Bank manager.
As this would be a routine screening test (as with blood donors) no declaration is necessary on insurance forms.
DECLARATION*
I have read and agree to the declaration below.
I have read the special health precautions needed and to the best of my knowledge, there is no reason why I should not donate my milk. I agree to my blood being tested.
Type Name*
First Last
Signature*

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Milk Donor Online Intake Form

Step 1 of 5 - Mother

Mother

Seriological Screening

Baby

PART A

PART B

PART C

PART D

Thank you for answering these questions!

Name	Age