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Current Donors

Donor Milk Checklist

Please complete this form to cover the dates your milk has been expressed and every time you send milk to the Milk Bank.
Has all milk been frozen within 24 hours
Have all hygiene guidelines been followed?
Has your Pump been sterilised by STEAM / MICROWAVE / CHEMICALS
Do all Bottles / Bags of milk have your name and the date expressed written on?
Have you Experienced any illness including any respiratory infections during this time?
Have you been in Good Health whilst expressing this milk?
Have you had a fever, virus or any breast infections during the time expressing this milk?
Have you taken any medication or supplements or undergone any other medical treatment? *** PLEASE WRITE DATES AND INFORMATION OF ANY MEDICATION OR SUPPLEMENTS TAKEN IN THE COMMENTS SECTION BELOW
PLEASE NOTE: IF YOU HAVE TAKEN ANTIBIOTICS PLEASE WAIT 72 HOURS AFTER COMPLETING YOUR COURSE BEFORE EXPRESSING MILK FOR THE MILK BANK. ***PLEASE ALSO WAIT 48 HOURS TO EXPRESS FOR THE MILK BANK AFTER TAKING IBUPROFEN
Have you exceeded 1-2 units of Alcohol once or twice a week? If Yes, please give details in the box at the bottom of this form.
Have you used nicotine replacement therapy including patches, chewing gum or inhalators (vaping)? If Yes, please give details in the box at the bottom of this form.

The Next Questions are about you since you became a Milk Donor. Please give FULL details at the bottom of this form if you answer YES to any of the following questions.

Have you had a blood transfusion, blood products or any piercings, tattoos or acupuncture? If Yes, please give details in the box at the bottom of this form.
Have you had any exposure to infection including HIV 1 or 2, hepatitis B or C, syphilis or herpes? If Yes, please give details in the box at the bottom of this form.
Have you visited an area where you may have been exposed to Ebola or Zika virus or do you have any reason to believe you may have been infected? If Yes, please give details in the box at the bottom of this form.
Have you had any immunisations? If Yes, please give details in the box at the bottom of this form.
Have you been exposed to environmental or chemical contaminants, for example contaminated water supply? If Yes, please give details in the box at the bottom of this form.
Have any of your answers to the Milk Bank’s Sexual Health History Questionnaire changed? Please give details in the box at the bottom of this form.
Has anything else changed since your enrolment? Please give details in the box at the bottom of this form.