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Donor Data Collection

Thank you for reaching out to us! We know you are busy and every second counts.

We know your time is valuable, we have attempted to make this as brief as possible. This survey should take less than 10 minutes to complete.

Following our review of your answers we will call you to review some of the information and provide guidance on the next steps in the screening process.

Thank you!

Human Milk Saves Lives! Donate today!

https://uamshealth.com/uams-milk-bank/

Initial Donor Screening Questionnaire

Please complete the following questionnaire and we will contact you in the next 1-2 business days to discuss your answers.

Thank you for your interest in the UAMS Milk Bank

First Name

* must provide value

Last Name

* must provide value

Full Legal Name (if different from above)

Date of Birth

* must provide value

M-D-Y

Today's Date

* must provide value

M-D-Y

Email address

* must provide value

Phone Number (primary)

* must provide value

Phone number type

Street address

* must provide value

City

* must provide value

State

* must provide value

zip code

* must provide value

What is your preferred way to be contacted?

May we email and/or text you with milk bank updates? (Emails will include our donor newsletter and requests for donor stories/baby photos.)

Yes

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How did you learn about the UAMS Milk Bank?

UAMS Webpage

Social Media

Google

Friend or Family member

Hospital or Clinic

TV or news

Can you share the name of the person or place who gave you information about the UAMS Milk Bank?

We ask that our donors try to give 100 ounces over the course of donation to the Milk Bank (not all at once or in a single donation). We completely understand that sometimes there may be reasons you have to stop sending your milk. Do you think you can commit to try to donate 100 ounces during the time you will be donating your milk?

Yes

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Are you a one-time donor or do you plan to continue donating your milk?

* must provide value

If you are giving a one time donation can you estimate how many ounces or bags of milk you will be donating?

What kind of freezer do you use (or will use) to store your milk in?

* must provide value

Are you donating milk that has already been collected?

* must provide value

Yes

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Our donors have many different reasons for donating their milk. We want to be sensitive to the needs of everyone.
In particular we hope that if you have suffered the loss of a child during the pregnancy or after birth you will feel comfortable sharing this with us. For those who have suffered a loss, now or ever, please know that we grieve with you and are so sorry. We know that the love for your child never stops and we hope that through donating milk we can help ease the loss even a little. Please let us know how we can help. You can also visit our bereavement page for information about donating after a pregnancy loss.
https://uamshealth.com/uams-milk-bank/bereavement/

Have you lost a pregnancy or child?
(this is not a required question)

If you feel comfortable, we would love to be able to help in any way we can and to know you and your child better. Please share any information you wish. Please do not feel obliged to comment if it is not comfortable for you.

What is your weekly or daily alcohol intake? (one drink or serving is 1.5 ounces of hard liquor, 5 ounces of wine, 12 ounces of beer, 10 ounces of wine cooler)

* must provide value

i don't drink alcohol

occasional sip, not daily

i have no more than one drink a week

i have a drink multiple times a week

i have a drink nearly every day

Are you willing to have your blood drawn for testing of HIV, Hepatitis B & C, HTLV (Human T-lymph trophic virus), and syphilis?

* must provide value

Yes

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Will you be able to come to UAMS in Little Rock for your bloodwork?

* must provide value

Yes

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If you are going to get your blood drawn at any site other than UAMS Main campus in Little Rock we will need to mail you the blood work supplies to ensure you are not charged for this blood draw.

Where would you prefer to go for bloodwork?
*UAMS facilities are preferred if at all possible: Jonesboro, Fayetteville, Pine Bluff, Helena, Texarkana, Batesville, Magnolia, Fort Smith, Springdale

* must provide value

Have you had a major illness or been hospitalized in the last year, not related to your pregnancy?

* must provide value

Yes

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Can you share some details about your hospitalization or major illness?

* must provide value

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Have you had an infection of the breast, such as mastitis, or a yeast infection of the nipple or breast in the last 3 months?

* must provide value

Yes

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Can you tell us when the infection occurred?

M-D-Y

Did you take any medications for the infection?

* must provide value

Yes

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Which medication (name) and dose (amount - in milligrams or number of pills, include number of times per day)

* must provide value

When was the last dose of the medication you took?

* must provide value

M-D-Y

Are you prohibited from giving blood or plasma donations for a medical reason? (exceptions are low body weight, pregnancy, iron deficiency anemia and breastfeeding)

* must provide value

Yes

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Why are you prohibited from giving blood or plasma donations?

* must provide value

fever or infection at the time of donation

high blood pressure

under 17 years old

no photo ID

History of Hepatitis B or C

risk factors for HIV/AIDS infection

travel

active tuberculosis

risk factors for Creutzfeldt-Jakob Disease (CJD, sometimes called Mad Cow Disease)

temporary prohibition for infection, vaccination, blood product transfusion, organ transplant

IV drug use or non-prescription drug use

Have you used nicotine containing products or use tobacco in any form in the previous 3 months? This includes vaping pens and other electronic nicotine devices (e-cigs), nicotine patches, nicotine inhalers, nicotine gum, and chewing tobacco.

* must provide value

Yes

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What was the date of your last use of a nicotine containing product?

* must provide value

M-D-Y

Have you used marijuana (also called cannabis or THC) in any form, for medical or casual use in the previous 3 months? (Includes edibles, gummies, or smokable devices.)

* must provide value

Yes

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What was the last date of use of any THC/marijuana/cannabis containing product?

* must provide value

M-D-Y

DURING PREGNANCY and BREASTFEEDING: Have you taken any prescribed or over-the-counter medications, vitamins or minerals, or any herbal preparations/teas including birth control methods during the time period of pregnancy, delivery, or breastfeeding?

*Medications given during labor or delivery such as anesthetics, epidurals or single dose antibiotics do not need to be listed.
*Prenatal vitamins, folic acid, and Iron supplements do not need to be listed.

* must provide value

Yes

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Please provide:
Name of medication: DOSE, Doses per day, START date, END date
(to the best of your ability)

* must provide value

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Do you (to your knowledge) have a chronic infection such as HIV, HTLV, Hepatitis A, B, or C, or active (untreated) tuberculosis (TB)?

* must provide value

Yes

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10a

Which infection?

* must provide value

HIV 1 or 2

HTLV 1 or 2

Active Tuberculosis

Hepatitis A

Hepatitis B

Hepatitis C

Do you have a personal history of cancer diagnosis at any time in your life?

* must provide value

Yes

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11a

Were you at any time diagnosed with one or more of the following?

* must provide value

leukemia

lymphoma

Hodgkin's Disease

Kaposi sarcoma

None of the above

11b

What kind of cancer and when was your diagnosis and treatment (include if/when treatment was completed and if you are taking ongoing medications or therapies)?

* must provide value

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Have you taken Isotretinoin (Accutane) or another oral retinoid for acne or skin conditions in the last 3 months?

* must provide value

Yes

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12a

When was your last dose of retinoid (such as Accutane)?

* must provide value

Have you taken Amiodarone (for arrhythmia or heart conditions) in the two years prior to the earliest milk you have stored?

* must provide value

Yes

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Have you had a blood transfusion or blood product (plasma, platelets, FFP or cryoprecipitate) or an organ or tissue transplant?

Please include ANY kind of transplant tissue. This includes skin, organ, brain coverings, corneas etc.

* must provide value

Yes

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14a

Please specify:

* must provide value

blood transfusion or blood product

organ transplant

tissue transplant (such as cornea, brain covering, skin graft)

14b

When was the last transfusion of a blood product?

14c

What kind of tissue transplant and when was it done? Are you taking any ongoing medications?

While you were still pregnant, did your baby receive a blood transfusion or have surgery (in utero transfusion or surgery)?

* must provide value

Yes

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Have you ever received a NON-STERILE or HOME body piercing (including ears), a tattoo, or had permanent makeup applied with non-sterile equipment? Please do not include tattoos or piercings done in a facility where sterile equipment is used (most commercial facilities).

* must provide value

Yes

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16a

When? (as close as possible in months/years)

* must provide value

Are you under the care of a medical provider (OB/Gyn, Family Medicine, Midwife)? May we send consent forms to release some of your medical records related to risk factors for donating your milk? (All information shared is protected by HIPPA and is stored in a secure location.)

* must provide value

Yes

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Please sign that the above information is, to the best of your knowledge, true.

If information about the above questions changes during your donation period, please contact the milk bank to discuss further.

* must provide value

Add signature

Does the donor authorize telephone signature of form?
"I, the UAMS staff, will place your initials in the donor signature field."
(only needed if information collected by phone.)

Yes

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UAMS Milk Bank Staff Signature of phone interview
(This field is for UAMS staff if this information is collected over the phone. Donor does not sign here.)

Add signature

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.