Related services

If yes, unfortunately we will not be able to accept a milk donation at this time.

About you

Prefix (Ms, Mrs, Miss, Dr other.) First name * Middle name Last name * Any previous surnames Date of birth (DD/MM/YY)* Imperial College Hospital Number (if known) NHS number * (if known)

If you are not sure of this, just enter '0000'

Address* Postcode * (Please note we cannot accept donations outside the M25)) Email address* Telephone number * Next of kin (and relationship to you) * Preferred method of communication email phone post

Ethnicity - please specify

Ethnic origin * Asian - Any Other Asian Background Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Black - Any Other Black Background Black or Black British - African Black or Black British - Caribbean Mixed - Any Other Mixed Background Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Other - Any Other Ethnic Group Other - Chinese White - Any Other White Background White - British White - Irish Prefer not to say

Occupation

What is your occupation Do you plan to return to work? Yes No If yes, please give expected date for returning to work

Medical history

GP name and address* GP postcode? * GP telephone number* Do you have any current medical conditions? Yes No If yes, please specify: Have you had any serious illness or surgery in the past? Yes No If yes, please specify: Have you had any health treatment (including IVF and/or diagnostic tests) in the past 12 months? Yes No If yes, please specify: Have you had recent exposure to any infections e.g. Herpes, Flu, Chicken Pox, Rubella etc.? Yes No If yes, please specify: Have you ever had any exposure to HIV 1 & 2, Hepatitis B and C, HTLV 1 & 2 or Syphilis? Yes No Have you ever had an inconclusive / positive test for HIV 1 & 2, Hepatitis B and C, HTLV 1 & 2 or Syphilis? Yes No If yes, please specify individual test, date and outcome: Have you ever been advised by a health professional that you are at increased risk of CJD (Creutzfeldt-Jakob disease sometimes referred to as Mad Cow Disease)? Yes No If yes, please specify including date of diagnosis:

Medication and supplements

Are you currently taking any prescribed or over the counter medication? Yes No If yes, please specify: Are you currently taking any herbal medications or supplements (e.g. Fenugreek, St Johns Wort, Ginko biloba, Herbal drinks)? Yes No If yes, please specify: Have you had any vaccinations in the past 6 months? Yes No If yes, please specify: Have you ever received human pituitary extract, brain (dura), corneal, scleral or other ocular tissue graft? Yes No If yes, please specify including date and location: Have you ever received a blood transfusion or blood products including blood thinners? Yes No If yes, please specify including date and location: Have you had the yellow fever vaccine in the last 6 months? Yes No

Travel

Have you or your partner travelled outside of the UK within the last 6 months? Yes No If yes, please specify including date and location: Have you or your partner returned from an area of the world where viral haemorrhagic fevers (e.g. Ebola Virus or Zika Virus) are endemic within the last 6 months? Yes No If yes, please specify including date and location:

Lifestyle* essential information for donor recruitment

Do you smoke / vape / use electronic cigarettes / use nicotine substitutes? Yes No Have you smoked / vaped / used electronic cigarettes / used nicotine substitutes in the past? Yes No If yes, please date of last use: Does anyone in your household smoke / vape / use electronic cigarettes? Yes No Do you take recreational drugs? Yes No Does anyone in your household take recreational drugs? Yes No Do you drink alcohol? Yes No If yes, specify number of units per week:

Please note: the maximum alcohol intake for breast milk donors is 1 to 2 units once a week. A unit is a small glass of wine, 1/2 pint of normal strength beer or a single pub measure of spirits. Please leave 12 hours after drinking any alcohol before expressing milk for donation to the milk bank.

Within the last 6 months have you had: Tattoos Body piercing Cosmetic treatment Semi permanent make-up None If yes, please specify including date and location: Within the last 6 months have you had acupuncture? Yes No If yes, please specify including date, name of acupuncturist, and clinic address with postcode: Have you ever been a blood donor? Yes No If yes, when did you last give blood:

About your baby

Baby's first and middle name* Gender: Female Male For multiples: Baby’s first and middle name Gender: Female Male Baby’s surname* Baby’s date of birth (DD/MM/YY)* Baby’s gestation at birth (e.g. 38 weeks) Date of baby’s discharge from hospital Place of birth Was your baby admitted to a Neonatal Unit? Yes No If yes, please specify in which Neonatal Unit(s) your baby received care: If yes, please also provide information about any illness(es) your baby has/had (if any): Has your baby ever received donor breast milk? Yes No If yes, please specify in which Neonatal Unit or Milk Bank your baby received donor breast milk from Do you have any other children? Yes No

If yes, please provide their names, date of birth and if they were breastfed below:

Name Date of birth Breastfed? Yes No Name Date of birth Breastfed Yes No Name Date of birth Breastfed Yes No If yes, please provide duration of breastfeeding Have any of your children received donor breast milk? Yes No If yes, please specify date and in which Neonatal Unit / Milk Bank they received donor breast milk from?

Donating breast milk

Can you confirm you intend to collect, freeze and donate breast milk to the Milk Bank? Yes No Do you anticipate producing a surplus of approximately 2 litres over an 8 week period? Yes No Have you ever donated breast milk to a Milk Bank before? Yes No If yes, please provide the date and Milk Bank donated to: Do you intend to donate milk already expressed and stored at home or on a Neonatal Unit? Yes No Where will your expressed milk be stored following registration? Home Hospital Other If hospital or other, please provide details e.g. hospital name and unit where milk is stored:

Please note that if your milk is stored at a hospital you would need to complete and submit a ‘Donor milk release form’ in order to release your milk to us – we will send the documentation to you if applicable.

Do you have access to a freezer with space to store milk in its own compartment? Yes No What type of freezer do you have? Chest Upright Fridge freezer Ice box in fridge Does your freezer have an external temperature monitor? Yes No If yes, please record the current reading:

Please note that your breast milk must be stored at -18 ◦C or cooler (-19◦C ; -20◦C , -21◦C ; -22◦C etc.). We will provide a thermometer in the Donor Pack following registration.

Do you use an electric or manual breast pump? Yes No If yes, please specify brand name and model including detail on whether it is electric or manual:

Please note we cannot accept milk collected using the drip method e.g. Haakaa pump or shells.

Are you happy to express into sterile bottles provided by the Milk Bank? Yes No How do you clean and sterilise your milk expression equipment?

Please specify, for example hand wash, air dry and steam sterilise: (Please note we cannot accept Milton tablets as a form of sterilisation).

Where did you hear about the Milk Bank? UKAMB website Online search Flyers posters Antenatal postnatal packs Health visitor doula Other If other, please specify

Blood test

Are you happy to have a blood screening for HIV/ HTLV/ Hep C / Hep B / Syphilis? Yes No Where would you like to have your blood test done? Local GPclinic Imperial Hospital If Imperial hospital, please specify which one: St Marys Hospital Hammersmith Hospital Charing Cross Hospital

<a href="https://www.imperial.nhs.uk/our-services/blood-tests">https://www.imperial.nhs.uk/our-services/blood-tests</a>

Covid assessment

During the last 14 days, have you or any member of your household:

Travelled abroad? Yes No Had close contact with someone with a probable or confirmed case of Covid? Yes No Attended a healthcare facility? Yes No Had any of the symptoms listed below? Fever Cough Shortness of breath Breathing difficulties A new continuous cough A high temperature A loss of or change in your normal sense of taste or smell anosmia None of the above Experienced any non-Covid illness (e.g. cold, flu, stomach bug) or felt unwell Yes No

Consent

I have been given the opportunity to ask any questions I may have, and understand that I may withdraw from becoming a breast milk donor at any time* I agree to provide the Milk Bank Staff with any additional information requested about my health and lifestyle* I consent to having a one off blood test for HIV/ HTLV/ Hep C / Hep B / Syphilis* I understand that the blood test can only be carried out after my 1st Milk donation and no previous test results will be accepted* I consent to small samples of my blood being stored for up to 30 years as per the NICE Clinical Guideline 93; Donor Breast Milk Banks (for milk bank purposes only and will not be shared)* I understand that I must inform the Milk Bank of any illness/symptoms that I or any of my close family members might have during the time I am a donor* I consent to my details being stored in a secure NHS facility according to NICE Clinical Guideline 93; Donor Breast Milk Banks - The Operation of Donor Breast Milk Bank Services* I consent to my donated breast milk being used on neonatal units, community units and in special clinical circumstances for term babies* I understand that all the milk I donate to the Milk Bank must be labelled and frozen within 24 hours, and that I should record details on a ‘Do it Safely’ form with every batch* I understand that I must record the freezer temperature daily from first expression to collection on a ‘Do it Safely’ form* I understand that I will be asked to inform the Milk Bank in advance about any travel I will be undertaking and how long I will be away for* I understand that if I drink any alcohol (max 2 units/week) I should leave 12 hours before expressing for the Milk Bank. A record must be made in the ‘Do it Safely’ forms provided* I understand that I can only donate until by child is 1 year old. In some circumstances the Milk Bank may have to reduce this period* I understand that I must inform the Milk Bank of the names and dates of any medication/supplements/ herbal teas that I may take whilst a registered breast milk donor* I understand that any donated milk will not be returned to the donor whether used or not as per the NICE Clinical Guideline 93; Donor Breast Milk Banks*

Optional

I consent to my breast milk being used for research purposes if it cannot be used as donor breast milk and would otherwise be discarded: Yes No I would be interested in connecting with other Breast Milk Donors Yes No