Donor Screening

Date*
First Name*
Last Name*
Address (Street, City and State)*
Phone*
Email*

When is a good time of day for us to contact you?

How did you hear about Mothers’ Milk Bank?

Are you a Kaiser Permanente patient? YesNo

Baby's Name*

Baby's Date of Birth*

Was the baby born preterm? YesNo

If yes, how many weeks

Is your baby in the hospital? YesNo

If yes, Name of hospital and contact information

Bereaved donor? YesNo

Surrogate donor? YesNo

Are you a previous donor? YesNo

Are you donating milk collected before you contacted the milk bank? YesNo

Please estimate amount of milk you can donate

Approximate oldest date of milk

Was the expressed milk stored in the freezer? YesNo

If refrigerated first, how many days before moving it to the freezer?

Has your milk been thawed, scalded or boiled? YesNo

If yes, please explain:

Were you, the baby, and other members of your household healthy during the time you collected this milk?
YesNo

If no, please explain:

Do you plan to be an ongoing donor?
YesNoUnsure