Pauline Sakamoto, R.N., M.S. established 1974 Ron Cohen, M.D.

Executive Director Medical Director

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.

Again, thank you for the “gift of life”.

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) __________

DONOR CONSENT PRIVACY AND CONFIDENTIALITY FORM

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.

8. I understand that I am encouraged to discontinue donating milk anytime my participation interferes

with my own family’s needs.

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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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

Donor’s Name : ______________________________ Signature:_____________________ Date: ________

(Optional) Designated Party Authorization for Release of Medical Information

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.

Designated Party: ________________________________ Phone: __________________ Relation: _____________

Designated Party: ________________________________ Phone: __________________ Relation: _____________

Designated Party: ________________________________ Phone: __________________ Relation: _____________

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Non profit #77-0131926
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 Donor Interview
Donor # (for office use) ___________

Date of Application: _______________

First Name: ________________________________ Last Name: ________________________________

Age: _______________ Birth Date: __________________ Ethnicity/Race: _______________________

Phone: (primary) ____________________ (secondary) __________________ other ________________

Address: ________________________________________________________ Apt. #: _____________

City: ______________________________ State: _________ Zip: ______________________________

Email address:_______________________________________________________________________

Do you plan to return to work? Yes No If yes, When? __________________________________

Present/Past Occupation_______________________________________________________________

Baby’s Name: _______________________________________________________________________

Sex: ____________ Age: ____________ Birth Date: ________________________________________

Birth Weight : __________________ Birth Height:_________________

Last Weight: ___________________ Last Height: __________________ Date: __________________

Was baby full term?  Yes No

If no, gestational age at birth: ______________ Is baby at home?  Yes  No

If in hospital, name and phone number of hospital contact: ___________________________________

Partner’s First Name: _______________________ Last Name: _______________________________

Occupation: _____________________________ Company: _________________________________

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1887 Monterey Rd. Suite 110 San Jose CA 95112 408-998-4550 Fax: 408-297-9208
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Non profit #77-0131926
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Mother’s Health Care Provider (OB-GYN/MIDWIFE/PRIMARY CARE PROVIDER)

Name: ________________________________________________________________________

Phone: _____________________________ *Fax number: _______________________________

Address: ______________________________________________________________________

City: ___________________________ State: _______ Zip Code: _________________________

 I will contact my doctor  Please contact my doctor

Baby’s Health Care Provider

Name: ________________________________________________________________________

Phone: _____________________________ *Fax number: _______________________________

Address: ______________________________________________________________________

City: ___________________________ State: _______ Zip Code: _________________________

I will contact my baby’s doctor Please contact my baby’s doctor

* required field

How did you hear about the Mothers’ Milk Bank? _____________________________________

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 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

this milk? Yes  No If no, please explain:

______________________________________________________________________________
______________________________________________________________________________

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:
_____________________________________________________________________________

Do you plan to be an ongoing donor? Yes  No

What kind of freezer do you have?

____inside refrigerator

____top or side of refrigerator

____deep freeze

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 Donor # (for office use) ____________

Donor’s Medical History and Health Habits

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,

ecstasy, or amphetamines? Yes No If yes, please answer the following:

a. What drug was taken and in what time period?

_____________________________________________________________________

b. Were the drugs taken by mouth, nose, smoking or injection? (please circle all that apply)

c. Are you using any of the above at present? Yes  No

d. What was the approximate date of last use? ________________________

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

medication(s) used and date medication was taken____________________________________________

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9. Have you expressed and stored milk before contacting the milk bank or with a previous baby? Yes No

10. What type of pump do you use? ______________________________________

11. Have you had any breast infections with this baby?  Yes  No If yes, please list types of

medication(s) or treatments and dates used. _________________________________________

12. Are you on any special diet? (e.g. vegetarian, low salt, low calorie, diabetic, dairy-free, etc.)

Yes  No If yes, please explain. ____________________________________________

13. If you are vegan are you supplementing your diet with Vitamin B12 daily?  Yes No  N/A

14.To how many children have you given birth?___________

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

shot? Yes No

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 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

If yes, please explain: _________________________________________________________________

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

needles and single use dyes  Yes  No

If yes, please list date(s): _________________________________________________________________

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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 Donor # (for office use)____________

29. Do you have insulin-dependent diabetes? Yes No

30. In the last 12 months have you tested positive for or been treated for Syphilis, Gonorrhea,or Chlamydia?

Yes No If yes, list treatment and dates:_____________________________________________________

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

If yes, please list immunizations and dates:

_____________________________________________________________________.

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

with the vaccination site of anyone else? Yes  No

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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Non profit #77-0131926
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 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

46. Do you have a family history of Creutzfeldt Jakob Disease? Yes  No

47. Do you have a personal history of cancer? 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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 Donor # (for office use) __________

51. Between 1980 and 1996, were you a member of US Military, a civilian military employee or a

dependent of a member of the military? Yes No

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

with hemophilia)? Yes  No If yes, please explain: ___________________________________________

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

months? Yes No

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?

(at least 28 days) Yes No

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 Donor # (for office use) ___________

Baby’s Medical History

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?

Yes No If yes, when? __________________________________________________________

4. Does your baby have frequent infections, such as colds, ear infections, diaper rash, or skin infections?

Yes No If yes, please explain:_________________________________________________________

5. Is your baby gaining weight and growing well? Yes  No If no, please explain:

________________________________________________________________________________

6. Is your baby totally breastfed? Yes  No If no, please explain: __________________________

_________________________________________________________________________________

Donor Name: ___________________________ Signature: ________________Date:_______________

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 Donor # (for office use) _____________

Medical Information Regarding Donor Mother’s Child

Date: __________________________

Baby’s name: ___________________ Baby’s Date of Birth: ____________ Medical Record #____________

I authorize _______________________________________________, (Healthcare Provider Name) to release the

requested medical information to the Mothers’ Milk Bank. I acknowledge that I can refuse to

sign this document and that I can have a copy of it by request.

_________________________________ _____________________________
Donor Mother’s Name (print) Donor Mother’s Signature

Instructions for the health care provider.

The mother of your patient has volunteered to be a donor to Mothers’ Milk Bank. You are NOT being asked to verify
the mother nor the safety of her milk supply. We will be screening the mother through other steps. If at any time her
baby’s growth and development are delayed while she is storing milk, please contact us.

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.

Thank you for your assistance.

Information Required From Health Care Provider

Date last seen in this office: __________________________

I am aware of no adverse effect for the health of baby ___________________________ if the mother

donates milk to the Mothers’ Milk Bank.

______________________________________
Provider Signature and Date

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 Donor # (for office use) ___________
Medical Information Regarding Donor Mother

Date: __________________________

I authorize _______________________________________ (Healthcare Provider Name) to release the

requested medical information to the Mothers’ Milk Bank. I acknowledge that I can refuse to sign this

document and that I can have a copy of it by request.

Donor Mother’s Name (print): __________________________________ Date of Birth: ______________

Donor Mother’s Signature: ___________________________ Medical Record #______________________

Instructions for the Health Care Provider

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:

Yes_____ No_____ Genital herpes?

Yes_____ No_____ Blood transfusion in the last 12 months?
Yes_____ No_____ TB, hepatitis, or prenatal viral infection?
Yes_____ No_____ Taking any medication on a regular basis? If so, please list.
________________________________, _________________________, ________________________

Please report: test results: date of test below

Rubella:  Immune  Non-Immune ______________

RPR: _________ ______________

HIV -1 & 2: _________ ______________
HTLV 1 & 2: _________ ______________
Hepatitis B (HBsAg): _________ ______________
Hepatitis C: _________ ______________

To the best of my knowledge, ___________________________ (name of patient) is in good health and

would be an appropriate donor to the milk bank.

______________________________________ __________________________
Provider Signature Date

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 Donor # (for office use) ____________

BLOOD TEST FOR MILK DONORS

All prospective donors must have blood testing if the required tests have not been
performed by her attending health care provider within 6 months prior to donation. The
actual tests are not performed until mothers have collected at least 100 ounces of milk and
whose medical consent forms have been signed and returned. Testing is done at no cost to
the donor.

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.

I would like to receive the lab request form through:

Email Regular Mail

Signature : _________________________________ Date: ____________

Donor Name: _______________________________

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