Donors

Thank you for wanting to become a breastmilk donor. Ideal candidates are in good health and have access to a fridge and freezer. There is no financial compensation but by filling out this form you are on your way to helping an infant in need. We canít thank you enough.
Name *


Surname *


Cell *


Alternative telephone number *


E-mail *


Address 1 *


Address 2


Suburb *


Postal code


City *


Province *


Country *


Would you like to sign up as a volunteer?


Occupation


Additional skills


Work address: company name


Work address: street


Work address: street 2


Work address: suburb


Work address: city


Work address: province


Work address: country


ID number *


Passport number


Your date of birth *


Race *


Are you a South African citizen *


Other nationality


Baby's name *


Baby's date of birth *


Name of family doctor *


Contact number of family doctor *


Declarations & Consent:

I give the SABR permission to collect and retain personal information as necessary *


I agree that necessary personal information may be shared with a contracted 3rd party for donor sign up purposes *


I agree that the information I have provided is true and correct *


I confirm that I give the SABR permission to keep record of my antenatal and other blood test results as necessary *


I confirm that I have been issued with a SABR issued cooler box and bottles *


I agree that the SABR cannot be held responsible for any lactation related advice that was requested from or given by a 3rd party *


Furthermore I confirm & consent to the following:

I confirm that I agree to be tested for HIV & agree to be retested every 3 months *


I confirm that I have been informed that my test results are confidential & will not be released without my written permission *


I confirm that I understand that I have the right to withdraw my consent for the test at any time before the test is complete *


I confirm that I have been given basic information on HIV & the testing process *


Or, I confirm that I was offered basic information as above but declined *


I confirm that I have been given the opportunity to ask questions concerning the test for HIV *


I confirm that my questions have been answered to my satisfaction *


I confirm that I grant the SABR permission to obtain my antenatal blood results in the event of me not issuing them with a copy *


I agree to allow the SABR to conduct random testing on my donated breastmilk for quality assurance purposes *


Questionnaire

1. Have you received a blood transfusion or blood products in the last 12 months? *


2. Do you regularly consume more than 50ml of hard liquor or its equivalent in a 24hr period? *


3. Are you a total vegetarian? *


If yes, do you supplement your diet with B12 vitamins?


4. Do you smoke or use tobacco products (snuff, chewing tobacco etc.)? *


5. Do you use habit forming drugs? *


6. Do you use cannabis? *


7. Do you suffer from any chronic conditions or illnesses? *


8. Do you use any prescribed medication? *

Prescribed medicines:
If you are using any prescribed medication not in the list above please specify in the field below:

If yes, please specify what prescribed medication you use


9. Do you regularly use over the counter medication? *

Over the counter medicines:
If you are using any over the counter medication not in the list above please specify in the field below:

If yes, please specify what over the counter medication you use


10. Do you use any herbal / homeopathic medications / remedies? *

Herbal medicines:
If you are using any herbal medication not in the list above please specify in the field below:

If yes, please specify what herbal, homeopathic medication or remedies you use


11. Do you use any galactogogues / substances to increase your breastmilk supply? *


If yes, please specify what galactogogues / substances you use to increase breastmilk supply


12. Do you use any cytotoxic or radioactive medication? *


13. Do you use any form of contraceptives? *


14. If you do use contraceptives please specify the type:


15. Are you in a monogamous relationship? *


16. Have you ever been diagnosed with:

Have you ever had hepatitis B, HIV or TB? *


Have you ever been diagnosed with Hepatitis B *


Have you ever been diagnosed with Hepatitis C? *


Have you ever been diagnosed with TB? *


Have you ever been diagnosed with Syphilis? *


Have you ever been diagnosed with HIV? *


17. Do you or have you ever had a sexual partner who:

Have you ever had a sexual partner who is at risk for HIV, takes habit-forming drugs or is a hemophiliac? *


Do you or have you ever had a sexual partner who Has / is at risk for HIV *


Do you or have you ever had a sexual partner who uses habit forming drugs *


Do you or have you ever had a sexual partner who is a Haemophiliac? *


18. When was the last time your spouse / consort / regular sexual partner was tested for HIV? *


19. Have you been coughing persistently (2 weeks or longer)? *


20. Have you been exposed to someone (work or home) who is coughing persistently? *


21. Are you exposed to harmful environments / chemicals due to your job? *


Do you have a copy of the results of your anti-natal HIV tests? *


If not, would you be prepared to undergo a rapid test for HIV at your expense and submit the results to the screening officer? *


Do you own a breast pump?


Unfortunately, we are not able to supply breast pumps, thus, unless you are able to hand express, owning a breast pump is essential.

If not, how will you be expressing to donate?


Do you have access to a freezer as we are only able to collect frozen milk?


Will you be a once off donor or a long term donor?


If you are a once off donor, when was the milk you are donating expressed?


How did you hear about us?


Please note, SABR reserves the right to outsource the sign up of donors to a third party medical professional.

I agree to the sharing of my information for sign up purposes only. *


Subject


Can we send you communication regarding South African Breastmilk Reserve


Please send communication via SMS/E-mail (Choose one or both)







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