I Want to be a Human Milk Donor

Thank you for your interest in becoming a human milk donor.  We strive to make the process of donating as easy as possible.  Before completing the steps below, please make sure you have looked over the Donor Selection Criteria.
If you pass this prescreening, please check the YES box in the form below.  If not, please check the NO box and tell us why.

Step One:

Complete all the required fields in the form below.

Reviewed Donor Selection Criteria?
 Yes No

Do you have any questions about the criteria?

Name (required)

Address

City

State

Zip Code

Email (required)

Phone (required)

Bereavement? yes no

Baby's Age (required)

One-time or Ongoing Donation (required)
 One-time Ongoing Donation

If one-time donation, can you provide at least 100 ounces?

Are you donating milk collected before contacting the Milk Bank?
 Yes No

Since you started storing your milk, have you taken or are you currently taking any prescribed or over-the-counter medications (used regularly or occasionally) including birth control, allergy meds or alternative treatments?
 Yes No

Are you willing to have your blood drawn to test for HIV, Hepatitis B&C, HTLV (human T-lymphotropic virus), and syphilis?
 Yes No

Have you had a major illness or been hospitalized in the last year?
 Yes No

Are you taking any vitamins, herbs, minerals or teas as treatments or supplements?
 Yes No

Do you use nicotine products?
 Yes No

Do you use illegal drugs?
 Yes No

Describe your daily or weekly intake of caffeine and alcohol?

How did you hear about us?

Comments

Step Two:

Check your email

Step Three:

Follow the instructions to download the Complete Donor Packet.  Please complete and return these FOUR forms as soon as possible.  You can mail, fax, or scan & email.  For any questions, call us at (317) 536 – 1670 or email chawkins@immb.org.