Milk Donor Interest with Pre-Screen updated 07.14.2022

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Milk Donor Prescreen

There is no greater gift to a family of a fragile NICU baby than donor milk. Milk donations are more than just nutrition, they are life-saving medicine! Over 1,000 lifesavers each year answer the call to save a life!

Because we serve critically ill infants, milk donors must meet specific safety requirements before milk can be accepted. This includes:
- In good health and not using tobacco products, CBD oil, marijuana, or recreational drugs.
- At low risk, along with their sexual partner(s) for communicable diseases (i.e. HIV/AIDS, Hepatitis B or C, or Syphilis).
- Collecting extra breastmilk beyond what your baby needs or milk that cannot be used by your baby.
- Complete the prescreen below. If you’d prefer to speak with a donor coordinator you can reach us at (317)536-1670.
Complete the prescreen below. If you’d prefer to speak with a donor coordinator you can reach us at (317)536-1670.
First Name*
Last Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Donor's Date of Birth
Baby's Date of Birth*
Are you interested in donating milk after the loss of your infant?*

YesNo
Are you interested in donating milk collected prior to contacting The Milk Bank?*

YesNo
In what month and year was the earliest milk pumped?*
Are you willing to complete the donor screening process including blood test (at The Milk Bank's expense) and make your first donation within 30 days?*

YesNo
I understand that I am DONATING my milk to The Milk Bank most often for critically ill infants that have no other options. The Milk Bank complies with national accreditation safety standards and is unable to provide financial compensation to milk donors.*

YesNo
Since giving birth have you taken ANY medications, vitamins, minerals, dietary or herbal supplements - please include both prescribed and over the counter. IMPORTANT - what is completely safe for healthy infants, may not be for critically ill babies so please list ANY and ALL medication, vitamins, minerals, dietary or herbal supplements you have taken, even if you believe them to be safe or if they were simply used to alter milk supply.*

YesNo
Please provide any details.
In the last 6 months have you used ANY tobacco or nicotine products including gum, patches, e-cigarettes/vaping, or use of a hookah? Have you used CBD oil, cannabis for medicinal or recreational purposes, either inhaled, ingested, or topically?*

YesNo
Please list any of the above that you have taken, along with the dates it was taken:*
How did you hear about us?

Health Provider Referral (Hospital, Lactation Consultant, Doula, Pediatrician, OB/GYN, etc)Health Organization (WIC, other milk bank, blood bank)Personal Contact (Friend, family)Internet Search (Including The Milk Bank website)Social MediaOutreach Event (Conference, Expo, Fair, etc)Media (TV, newspaper, etc)My EmployerGoogle AdI'm a prior donor or recipient!
Would you like an interpreter?*

YesNo
What is your preferred language?
Please provide any additional information you feel is relevant to your donation or ask any additional questions here.
I consent to The Milk Bank contacting me by email, voicemail, MMS text messages or other means. I understand message/data rates may apply and that I may opt out by notifying the Milk Bank in writing. I authorize The Milk Bank to leave messages on all contact numbers and information that I provide.*

YesNo
Thank you for your heart to give! We know lots can change with little ones - to serve you best, please revisit this site when you are closer to the 30 day donation window. Until then, please follow us on social media to meet some of the little faces you’ll be helping! If you would like to request follow up at a later time, please include best time (i.e. month and time of day) here so that we can reach back out to you. You can always direct questions about the donation process to milkdonor@themilkbank.org or by calling 317-536-1670.
This is the best time and date to follow up with me:
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