Please report any illness to the NYMB Donor Coordinators as soon as possible!

If you engage in the following behaviors you may increase your risk of blood borne disease and sexually transmitted disease such as HIV and hepatitis, and you may not qualify for milk donation:

• Having unprotected sex with multiple partners
• Having anal sex
• Having sex with a partner who has sex with multiple partners or who has anal sex with men
• Injecting recreational drugs

To protect yourself from HIV and other sexually transmitted infections:

• Get tested and know your partner's HIV status. Talk to your partner about HIV testing and get tested before you have sex.
• Have less risky sex. Oral sex is much less risky than anal or vaginal sex. Anal sex is the riskiest type of sex for HIV transmission.
• Use condoms. Use a condom correctly every time you have vaginal, anal, or oral sex.
• Limit your number of sexual partners. The more partners you have, the more likely you are to have a partner with HIV whose HIV is not well controlled or to have a partner with a sexually transmitted disease (STD). Both of these factors can increase the risk of HIV transmission. If you have more than one sexual partner, get tested for HIV regularly.
• Get tested and treated for STDs. Insist that your partners get tested and treated too. Having an STD can increase your risk of becoming infected with HIV or spreading it to others.
• Don't inject drugs.

The following occupations put you at increased risk for exposure to blood borne pathogens:

• Health Care Workers
• Correctional Health Care Workers
• Dental Workers
• First Responders
• Body Artists

How We Collect Information About You: The New York Milk Bank and its employees and volunteers collect data through a variety of means including but not necessarily limited to letters, phone calls, emails, voice mails, and from the submission of screening materials that is either required or necessary to process milk donors, donor milk recipients or other requests for assistance through our organization.

What We Do Not Do With Your Information: Information about your financial situation and medical conditions and care that you provide to us in writing, via email, on the phone (including information left on voice mails), contained in or attached screening forms, or directly or indirectly given to us, is held in strictest confidence.

We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services that is considered patient confidential, is restricted by law, or has been specifically restricted by a patient/client in a signed HIPAA consent form.

Information We Do Not Collect: We do not use cookies on our website to collect data from our site visitors.

Limited Right to Use Non-Identifying Personal Information From Biographies, Letters, Notes, and Other Sources: Any pictures, stories, letters, biographies, correspondence, or thank you notes sent to us become the exclusive property of NYMB. We reserve the right to use non-identifying information about our clients (those who receive services or goods from or through us) for fundraising and promotional purposes that are directly related to our mission.

Clients will not be compensated for use of this information and no identifying information (photos, addresses, phone numbers, contact information, last names or uniquely identifiable names) will be used without client's express advance permission.

You may specifically request that NO information be used whatsoever for promotional purposes, but you must identify any requested restrictions in writing. We respect your right to privacy and assure you no identifying information or photos that you send to us will ever be publicly used without your direct or indirect consent.

Donor's Obstetrical and Lactation History

1. Have you previously breastfed or provided your milk to any other children?

   Yes Please select an option. No
   If yes, was your experience satisfactory? If no, please explain
2. Have you ever expressed and stored milk with a previous baby?

   YesPlease select an option. No
3. Do you currently have milk that has been expressed and stored?

   YesPlease select an option. No
   If yes, how many ounces?
   
   
   Have you heat-treated your milk in any way such as warming, scalding, boiling, or thawing after freezing?

   YesPlease select an option. No
   If yes, please describe
   
   
   If yes, have you placed any freshly pumped milk on top of previously cooled milk in the fridge or freezer when collecting milk to donate?

   YesPlease select an option. No
   Please describe
   Please note that when donating freshly pumped milk, do not stack or layer it on top of milk that has already been cooled in the fridge or freezer. All milk must be chilled before combining.

4. What type of pump(s) are you using to express your milk?

   Electric

   Battery-Operated

   Hand-held

   Hand Expression

   Pump Brand:

   Do you use a Haakaa or other passive pump?

   Yes Please select an option. No
5. Have you had a breast infection since pumping?

   YesPlease select an option. No
   If yes, describe and give dates:
   If you were treated with medication, which medication? Include start and end dates of use:
6. Where do you usually pump? Please select all that apply:

   Home

   Office

   Other:  

   If you don't pump at home or the office, where do you keep your pump parts and milk between pump sessions? Please explain.
7. Could you describe your process for pumping, collecting, and storing your milk in as much detail as possible?
8. Do you use the bottles that came with your pump to collect your milk?

   YesPlease select an option. No
   If not, what are you using?
9. Describe the process of how you get your milk into a milk storage bag.
10. Do you ever combine milk that you've pumped on different days into the same storage bag? If so, what date do you write on the bag?
11. Are you on any special diets?

    YesPlease select an option. No

    If yes, please check all that apply:

    Dairy-Restricted *
    Kosher
    Vegan **
    Soy-Free
    * No butter or non-fat milk powders, etc. Are you reading labels?

    YesPlease select an option. No
    ** If vegan, do you take a B12 supplement?

    YesPlease select an option. No
12. Did you experience any complications during this pregnancy, childbirth, or postpartum, such as infections, excessive bleeding, or high blood pressure?

    YesPlease select an option. No
    If yes, please explain and be as specific as possible:
13. Did your baby have an in-utero transfusion or transplant?

    YesPlease select an option. No
    If yes, please explain:

Donor's Medication, Herbal and Recreational Drug Use

14. Do you take any medications on a regular basis?

    YesPlease select an option. No
    If yes, please list the name of the medication, dosage and frequency taken:
15. Did you take ANY medications or supplements in the week before or while pumping the milk to be donated?

    It is crucial for us to be aware of any medications you took during the time when the milk being donated was pumped. This encompasses both prescription and over-the-counter drugs, including but not limited to birth control pills, antibiotics, laxatives, stool softeners, allergy medications, diabetic medications, blood pressure medications, cholesterol medications, asthma medications, and pain medications. The well-being of the babies who will receive the milk is contingent on your honesty and transparency.

    YesPlease select an option. No
    Please list the name of the medication or supplements, dosage and dates taken:
16. Did you take ANY herbs or essential oils in the week before or while pumping the milk that is being donated?

    This includes herbal remedies, special medicinal or herbal teas.

    YesPlease select an option. No
    Please list names of herbs, dosage and dates taken:
17. Do you take any dietary supplements?

    YesPlease select an option. No

    Check all that apply:

    Multivitamin

    Omega-3 (fish oil, flaxseed oil, krill oil)

    Iron

    Calcium

    Probiotics

    Lecithin

    Other:
18. Do you use tobacco products?

    YesPlease select an option. No

    Check all that apply:

    Cigarettes/Vape Pens

    Chewing Tobacco

    Nicotine Gum

    Nicotine Patch

    Cigars

    Pipe
19. Do you drink caffeinated beverages?

    YesPlease select an option. No
    If so, please specify the type and the daily or weekly intake:
20. Since giving birth, have you consumed alcohol?

    YesPlease select an option. No
    What type of alcohol do you drink?
    What is the average number of drinks per night or frequency of consumption?
    How long do you wait to pump after consuming alcohol?
21. Have you used any recreational or medicinal marijuana in the past five years?

    YesPlease select an option. No
    If so, please provide the timeframes and types used.
22. Has your sexual partner or any members of your household used any recreational or medicinal marijuana in the past five years?

    YesPlease select an option. No
    If so, please provide the timeframes and types used.
23. Have you used any illegal drugs, such as cocaine, LSD, ecstasy, amphetamines, or heroin, in the past five years?

    YesPlease select an option. No
    If applicable, please list the drug(s) taken and the time period during which they were consumed.
    How were the drugs ingested? Check all that apply:

    Oral

    By nose

    Smoking

    Edible

    Injection
24. Has your sexual partner or any members of your household used any illegal drugs such as cocaine, LSD, ecstasy, amphetamines, or heroin, in the past five years?

    YesPlease select an option. No
    If applicable, please list the drug(s) taken and the time period during which they were consumed.
    How were the drugs ingested? Check all that apply:

    Oral

    By nose

    Smoking

    Edible

    Injection

Donor's Medical History

25. Have you ever been instructed not to donate blood or milk?

    YesPlease select an option. No
    If so, please provide the reason.
26. In the past year, have you undergone surgery or received medical attention for a significant illness (excluding pregnancy)?

    YesPlease select an option. No
    If so, please provide details.
27. In the past 12 months have you been exposed to Hepatitis A and/or received a gamma globulin shot?

    YesPlease select an option. No
28. Have you or your sexual partner had jaundice (excluding immediately after your own birth), liver disease, or hepatitis?

    YesPlease select an option. No
    If so, please provide details, including dates.
29. In the last 12 months have you or your sexual partner had close contact with a person with jaundice or viral hepatitis?

    YesPlease select an option. No
    If so, please provide details, including dates.
30. Have you completed the Hepatitis B vaccine series?

    YesPlease select an option. No
31. In the past 12 months have you or your sexual partner had intimate contact with someone with Hepatitis, HTLV or Hemophilia?

    YesPlease select an option. No
    If so, please provide details, including dates.
32. In the past 12 months have you or your sexual partner had intimate contact with someone with HIV or AIDS?

    YesPlease select an option. No
    If so, please provide details, including dates.
33. In the past 12 months have you or your sexual partner tested positive or been treated for a sexually transmitted disease (syphilis, gonorrhea, or chlamydia)?

    YesPlease select an option. No
    If so, please provide details, including dates.
34. Do you or your sexual partner have a history of oral herpes (cold sores)?

    YesPlease select an option. No
    If so, please indicate the frequency of outbreaks and the date of the most recent outbreak.
    Please specify if you or your sexual partner have taken any oral or topical medications for oral herpes.
35. Have you changed sexual partners in the last three months?

    YesPlease select an option. No
36. Have you had sex during the past 3 months with a man who has had sex with another man in the past 3 months?

    YesPlease select an option. No
37. Have you or your partner(s) undergone body piercing, tattooing, or received permanent makeup using needles in the past 12 months?

    YesPlease select an option. No
    If yes, did you or your partner(s) confirm with the artist/technician that single-use needles and/or dyes were used during procedure?
38. Have you or your sexual partner received acupuncture with non-sterile needles within the past 12 months?

    YesPlease select an option. No
39. In the past 12 months have you been exposed to any toxins or heavy metals such as lead, mercury, or gold?

    YesPlease select an option. No
    If so, please specify the type and date of exposure
40. Has your home been treated with chemicals in the past year?

    YesPlease select an option. No
    If yes, what kind?
41. In the past 12 months have you or your sexual partner had an accidental needle stick or exposure to someone else's blood?

    YesPlease select an option. No
    If yes, please explain and include dates:
42. In the last 12 months, have you or any of your sexual partners served time in juvenile detention, jail, or prison for a period exceeding 72 hours?

    YesPlease select an option. No
    If yes, please specify the dates and provide a brief explanation.
43. Have you or your sexual partner ever received payment for oral sex or sexual intercourse?

    YesPlease select an option. No
44. Have you or any of your sexual partners ever been diagnosed with tuberculosis (TB), had exposure to TB, tested positive for TB, or received a positive chest X-ray result?

    YesPlease select an option. No
    If so, kindly specify the dates and provide a brief explanation.
45. Have you or any of your sexual partners received treatment for tuberculosis (TB) in the past?

    YesPlease select an option. No
    If yes, please provide details about the treatment received and the dates it was administered.
    Has a follow-up chest X-ray been performed after any treatment for TB? If yes, please indicate the date of the examination
46. Do you or anyone in your household currently have a cough that has lasted longer than 3 weeks?

    YesPlease select an option. No
    If yes, please explain
47. Have you or anyone in your household been coughing up blood or running a fever?

    YesPlease select an option. No
    If yes, please explain
48. Have you ever been diagnosed with heart disease or high blood pressure?

    YesPlease select an option. No
    If yes, please list medications taken and dates
49. Do you have insulin-dependent diabetes?

    YesPlease select an option. No
50. Have you or your sexual partner ever had a skin disease or unexplained skin lesions

    YesPlease select an option. No
    If yes, please explain
51. Within the last 6 months, have either you or your sexual partner been diagnosed with Chickenpox or Shingles?

    YesPlease select an option. No
    If yes, when?
52. Have you received any vaccinations in the past 12 months?

    YesPlease select an option. No

    Please provide the type and dates of any vaccinations you have received

    Vaccine

    Dates

    Vaccine

    Dates

    Vaccine

    Dates

    Vaccine

    Dates
53. Have you experienced any illnesses or complications as a result of receiving a vaccine?

    YesPlease select an option. No
    If so, please provide an explanation.
54. Within the last 8 weeks, have you received the Smallpox vaccine or been in close proximity to someone else who has received the vaccine?

    YesPlease select an option. No
    If you received the Smallpox vaccine, has the scab fallen off your skin on its own?

    YesPlease select an option. No
    If you have been in close proximity to someone who received the Smallpox vaccine, have you developed any new skin rashes or sores since that time?

    YesPlease select an option. No
55. In the last 12 months have you been bitten by a dog suspected of having rabies?

    YesPlease select an option. No
56. Have you received injections or experimental vaccines for rabies exposure in the past 12 months?

    YesPlease select an option. No

    If yes, please provide the type and dates of any vaccinations you have received

    Vaccine

    Dates

    Vaccine

    Dates
57. Do you have a history of yeast infections (oral, vaginal, systemic) or unexplained white sores or lesions in your mouth?

    YesPlease select an option. No
    If yes, please explain:
58. Do you have or have you had unexplained weight loss, persistent diarrhea, fever or night sweats?

    YesPlease select an option. No
    If yes, please explain and include dates:
59. In the last 12 months have you received a blood transfusion, blood products or an organ/tissue transplant?

    YesPlease select an option. No
    If yes, please explain and include dates:
60. Have you been diagnosed with vCJD, CJD, or any transmissible spongiform encephalopathy (TSE), or has a blood relative been diagnosed with CJD (excluding sporadic or iatrogenic cases)?

    YesPlease select an option. No
61. Have you received a human cadaveric (allogeneic) dura mater transplant?

    YesPlease select an option. No
62. Do you have a personal history of cancer?

    YesPlease select an option. No
    Leukemia

    Lymphoma

    Hodgkin's Disease

    Kaposi Sarcoma

    Other
    If yes, please explain treatment and include dates:

Travel History

63. Have you lived in, traveled to, or been born in any African country since 1977?

    YesPlease select an option. No
    If so, please provide details including the country name and dates of your stay.
64. During the past six months, have you received a diagnosis for the Zika Virus?

    YesPlease select an option. No
65. Have you lived in or visited a region with ongoing Zika Virus transmission, such as the Caribbean, South America, or Central America?

    YesPlease select an option. No
    If so, please specify the location and dates.
66. Has a male sexual partner of yours lived in or traveled to a region with ongoing Zika Virus transmission?

    YesPlease select an option. No
    If so, please specify the location and dates.

Other

67. Have you received a diagnosis or been suspected of having COVID-19?

    YesPlease select an option. No
    If yes, what was the date of your diagnosis?
    When did you first experience symptoms?
    When did symptoms subside?
68. Have you received a diagnosis or been suspected of having monkeypox?

    YesPlease select an option. No
    If yes, what was the date of your diagnosis?
    When did you first experience symptoms?
    When did symptoms subside?

Infant's Medical History

69. Was your baby jaundiced?

    YesPlease select an option. No
    If yes, how long did it last?
70. Has your baby ever had a yeast infection such as thrush or a yeast diaper rash?

    YesPlease select an option. No
    If yes, please explain and include dates
    Please list any medications used, and the dates they were taken
71. Has your baby been exposed to any communicable diseases, such as chicken pox, measles or mumps?

    YesPlease select an option. No
    If yes, please explain and include dates
72. Does your baby have frequent infections, such as colds, ear infections, diaper rash or skin infections?

    YesPlease select an option. No
    If yes, please explain and list dates
73. Is your baby gaining weight and meeting appropriate growth milestones?

    YesPlease select an option. No
    If not, please provide an explanation.
74. Has your baby been exclusively fed human milk?

    YesPlease select an option. No
    If no, please explain

Thank you for taking the time to complete the Donor & Infant Health History

I hereby certify to the best of my knowledge I have answered all questions truthfully. I do not consider myself to be a person at risk for spreading the HIV/ AIDS virus, COVID-19 or any other disease.

1. By signing this consent form I confirm that I have voluntarily chosen to donate my breast milk to The New York Milk Bank (NYMB).
2. I have received detailed information regarding the NYMB Screening Process, including:
   1. Information I am required to provide about my personal and family history
   2. Pre-donation medical testing
   3. Any and all medications that I am currently taking or have taken within the last 30 days
   4. If applicable, the date on which I last smoked cigarettes, consumed alcohol, or took illegal drugs
3. All my questions about the donation process have been answered to my full satisfaction.
4. 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 institution or an eligible recipient in the community receiving the milk.
5. I understand that a minimum of 150 oz. (about 4,400 ml) of my frozen breast milk is required for me to be accepted as a donor. I understand that I must follow the donation and collection procedures as outlined by NYMB and that failure to do so may result in my being removed from the NYMB donor program.
6. I am aware that once my milk has been donated it will be in the custody and control of NYMB and cannot be returned to me.
7. I understand that all donor information is confidential personal health information (PHI) and will be kept in a secure, HIPAA-compliant location controlled by NYMB.
8. I understand that a sample of my milk will be tested for harmful bacteria after pasteurization and for macronutrient composition (amounts of protein, fat and milk sugar (lactose). I understand that if any harmful bacteria, etc. are discovered during testing I, and/or my baby’s Health Care Provider will be notified with the results if they are relevant to my health or my baby’s health.
9. I understand that my milk may be pooled with milk from 1-4 more donors to optimize the nutrient content.
10. I acknowledge that my milk or data about the milk, as well as my blood samples or data about my blood samples, may be used for research purposes by NYMB and/or NYMB-approved third party institutions, if NYMB determines such needs exist. In such cases, NYMB will remove/redact all relevant PHI in compliance with HIPAA and other federal or state laws concerning PHI and/or personal identity information (PII).
11. I have read all of the information about HIV and the blood tests done for donors. I do not consider myself to be a person at risk for spreading HIV. I understand that the laws of the State of New York require positive test results to be reported to the local public health authorities.
12. I agree to have my blood tested every 6 months, at the expense of NYMB through an NYMB-approved provider, while I am donating milk as described in ‘Blood Testing Required for Milk Donors’ and understand that I, and/or my baby’s Health Care Provider will be notified with the results if they are medically relevant to my health or to my baby’s health.
13. I agree that I will refrain from smoking, drinking or taking recreational or illegal drugs for the duration of my donor relationship with NYMB. I understand that failure to abide by this paragraph will result in my removal from the NYMB donor program and, pursuant to paragraph 8, NYMB may notify my baby’s health care provider if testing of my milk reveals use of such substances.
14. I understand that acceptance as a milk donor is in no way an indication that my milk is safe to share with individuals outside of the milk bank. Milk banks take several steps to ensure the safety of donor milk beyond health screening of the donor. Therefore, my acceptance as a donor is not a guarantee of the safety of my milk for a recipient if it has not been pasteurized and tested by The New York Milk Bank.
15. 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 NYMB:
    1. If I, my baby, or a member of my household has an illness's involving a fever or requiring medications for me or my baby.
    2. When I have been exposed to a contagious illness or disease, including monkeypox.
    3. When I take any new medications, or herbal or dietary supplements.
    4. When any new circumstances in my life contraindicating milk donation arise.
16. I understand that failure to notify NYMB in a timely manner of any of the conditions outlined in paragraph 15(a) – (c), above, may result in being removed from the NYMB donor program.
17. I understand that I am encouraged to discontinue donating milk anytime my participation interferes with my own baby, my own or my family needs.
18. I understand that I can withdraw from being a donor at any time without providing a reason.
19. I hereby certify, to the best of my knowledge that I understand and have answered all the questions truthfully during the screening process.

All prospective milk donors must have blood testing. The actual tests are not performed until you have collected at least 100-150 ounces of milk and your screening forms have been signed and returned.

Testing is done at no cost to you, the donor. Please do NOT offer to show your insurance card. This will only result in your insurance company being billed. All test results are confidential.

The human immunodeficiency virus (HIV) test detects antibodies to HIV or the AIDS virus. While the risk of acquiring HIV/AIDS is very low for any infant receiving another mother’s milk, 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 virus detects almost everyone who carries the antibody to the virus, it occasionally is false positive.

Other viruses breastmilk donors are screened for are: Hepatitis B, Hepatitis C, HTLV-1 and 2 (Human T-cell Lymphotropic Virus) and Syphilis. If your results are positive for any of these viruses (including a false positive reaction on any test), we will not be able to use your milk.

If any of your tests are positive, the health care provider named on your screening form will be notified to discuss the confidential results with you. These results, if positive, are reportable to the New York State Department of Health. Donors who wish to have copies of their test results must request in writing that all results be forwarded to their named health care provider. A medical provider must interpret test results.

I have read the Consent for Blood Work and have no further questions about the blood tests which will be performed on my blood sample.