I voluntarily choose to donate my breastmilk to Mothers’ Milk
Bank of Florida, a not-for-profit organization accredited by the
Human Milk Banking Association of North America (HMBANA). I
understand that I will not be paid for the breastmilk that I
donate. I am also aware that my milk will not be sold, but a
processing fee will be charged to the recipient of the milk. My
donated milk and non-identifiable data about my milk may be used
for research purposes.
I understand that all my donor information is confidential.
I have received a copy of the MMBFL HIPAA Privacy Statement.
I am aware that once my milk has been donated, it becomes
property of Mothers’ Milk Bank of Florida and cannot be returned
to me. If my milk is dispensed to another HMBANA Milk Bank, my
records will be shared with them.
I will make every effort to see that my breastmilk is donated
according to the instructions provided. I understand that it is
my responsibility to notify Mothers’ Milk Bank of Florida:
- If I, my baby, or a member of my household, become ill.
When I take any medications or herbal or dietary supplements.
- When I have questions about being a breastmilk donor.
When I have been exposed to a contagious illness or disease.
- When I experience a decrease in my milk production.
I understand that I am encouraged to discontinue breastmilk
donation, any time my participation interferes with my own
I hereby certify to the best of my knowledge that I understand
and have answered all of the questions in my donor screening
packet truthfully. I have reviewed and understand the
information provided to me regarding the spread of HIV. I do not
consider myself to be a person at risk for spreading HIV.
I have read all of the information about HIV and the blood tests
for breastmilk donors. I agree to have my blood tested as
described. I understand that I will be notified if the results
are of medical significance.
I understand that a sample of my breastmilk will be tested for
bacteria after pasteurization.
I understand that acceptance by Mothers' Milk Bank of Florida as
a donor is in no way an indication that my milk is safe to share
with individuals outside the milk bank process. Milk banks take
several steps to assure the safety of donor breastmilk beyond
the health screening of the donor. Therefore, it is a
misrepresentation to use the milk bank screening process to
guarantee the safety of my breastmilk for a recipient, if it has
not gone through processes similar to those used by a milk bank.