Donors

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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 can’t 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?
Yes No

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 *
Black White Coloured Indian Asian

Are you a South African citizen *
Yes No

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 *
Yes No

I agree that necessary personal information may be shared with a contracted 3rd party for donor sign up purposes *
Yes No

I agree that the information I have provided is true and correct *
Yes No

I confirm that I give the SABR permission to keep record of my antenatal and other blood test results as necessary *
Yes No

I confirm that I have been issued with a SABR issued cooler box and bottles *
Yes No

I agree that the SABR cannot be held responsible for any lactation related advice that was requested from or given by a 3rd party *
Yes No

Furthermore I confirm & consent to the following:

I confirm that I agree to be tested for HIV & agree to be retested every 3 months *
Yes No

I confirm that I have been informed that my test results are confidential & will not be released without my written permission *
Yes No

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 *
Yes No

I confirm that I have been given basic information on HIV & the testing process *
yes No

Or, I confirm that I was offered basic information as above but declined *
Yes No

I confirm that I have been given the opportunity to ask questions concerning the test for HIV *
Yes No

I confirm that my questions have been answered to my satisfaction *
Yes No

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 *
Yes No

I agree to allow the SABR to conduct random testing on my donated breastmilk for quality assurance and research purposes *
Yes No

Questionnaire

1. Have you received a blood transfusion or blood products in the last 12 months? *
Yes No

2. Do you regularly consume more than 50ml of hard liquor or its equivalent in a 24hr period? *
Yes No

3. Are you a total vegetarian? *
Yes No

If yes, do you supplement your diet with B12 vitamins?
Yes No

4. Do you smoke or use tobacco products (snuff, chewing tobacco etc.)? *
Yes No

5. Do you use habit forming drugs? *
Yes No

6. Do you use cannabis? *
Yes No

7. Do you suffer from any chronic conditions or illnesses? *
Yes No

8. Do you use any prescribed medication? *
Yes No

Prescribed medicines:
Anti depressants Anti hypertensives Antibiotics Anticoagulants Asthma inhalers Baclofen Carbimazole Clexane Codeine Domperidone Ibuprofen Insulin Levothyroxine Mesalazine Metformin Omeprazole Prednisolone Progesterone Propothiouracil Sleeping tablets Steroid creams Tramadol

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? *
Yes No

Over the counter medicines:
Antacids Aspirin Bulk forming laxatives Cetirizine Chlorpheniramine to relieve symptoms of hay fever Cough mixtures that do not cause drowsiness and do not contain decongestants Folic acid Head lice treatment Imodium for diarrhoea Loratadine Lozenges for sore throat Moisturizers for the relief of eczema Nasal spray for colds .i.e. xylometazoline Nasal sprays or eye drops for hay fever Nicotine patches nicotine replacements Paracetamol Sofradex for conjunctivitis Threadworm treatment (Vermoxil) Vitamins

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? *
Yes No

Herbal medicines:
Fenugreek Ginko Biloba St Johns Wort

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? *
Yes No

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

12. Do you use any cytotoxic or radioactive medication? *
Yes No

13. Do you use any form of contraceptives? *
Yes No

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

15. Are you in a monogamous relationship? *
Yes No

16. Have you ever been diagnosed with:

Have you ever had hepatitis B, HIV or TB? *
Yes No

Have you ever been diagnosed with Hepatitis B *
Yes No

Have you ever been diagnosed with Hepatitis C? *
Yes No

Have you ever been diagnosed with TB? *
Yes No

Have you ever been diagnosed with Syphilis? *
Yes No

Have you ever been diagnosed with HIV? *
Yes No

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? *
Yes No

Do you or have you ever had a sexual partner who Has / is at risk for HIV *
Yes No

Do you or have you ever had a sexual partner who uses habit forming drugs *
Yes No

Do you or have you ever had a sexual partner who is a Haemophiliac? *
Yes No

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)? *
Yes No

20. Have you been exposed to someone (work or home) who is coughing persistently? *
Yes No

21. Are you exposed to harmful environments / chemicals due to your job? *
Yes No

Do you have a copy of the results of your anti-natal HIV tests? *
Yes No

If not, would you be prepared to undergo a rapid test for HIV at your expense and submit the results to the screening officer? *
Yes No

Do you own a breast pump?
Yes No

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?
Yes No

Will you be a once off donor or a long term donor?
Once off donor 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. *
Yes No

Subject

Can we send you communication regarding South African Breastmilk Reserve
Yes No

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

Please note;
Yes, I HAVE READ AND UNDERSTAND WHAT I AM CONSENTING TO AS OUTLINED ON THE POPIA CONSENT TERMS AND CONDITIONS AND IN THE INFORMATION PRIVACY POLICY AND CONSENT TO THE PROCESSING OF MY PERSONAL INFORMATION.
I understand that the outcome OF MY APPLICATION is at the sole discretion of the SABR and I will abide by it.