Research Intake Form

As an applicant, you must:

· Submit a research protocol with background, the research question, the timeline, and the study protocol.

· Conduct research that increases understanding of human milk's unique properties and/or its appropriateness for specific medical conditions or populations.

·Conduct a survey/qualitative/epidemiological inquiry related to human milk and/or human milk banking.

· Agree to pay the processing fee charged by the milk bank supplying milk for my research.

· Agree to acknowledge any relevant milk banks in publications pertaining to this study.

Disclaimers:

· HMBANA does not support research that strives to create a substitute for human milk.

· HMBANA does not support research funded by an organization that produces a substitute for human milk.

· Approval by the HMBANA Research Committee does not guarantee the availability of donor milk. Researchers are encouraged to work with HMBANA member milk banks.

· Inquiries from the industry are rarely supported.

Question Title

* 1. Contact Information

Name of Principal Investigator (PI)

Project Contact (person responsible for project communications, if different than above)

Name of Institution

Mailing Address

Phone Number

Email Address

Fax Number

Question Title

* 2. Research Project

Research Question

Purpose of Project

Length of Study

Funding Sources for Study

Intended Use of Results

Investigator's Names and Credentials (#1)

Investigator's Names and Credentials (#2)

Investigator's Names and Credentials (#3)

IRB Approval Date and Number, or Proof of Exemption (attach documentation in #3 below)

Question Title

* 3. Supporting Documentation (IRB documentation, abstract, protocol, survey, and other relevant documents)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 4. Human Milk Needed

Yes

Other (Please specify)

Question Title

* 5. Human Milk Information

Total Volume Needed

Total Number of Samples

Number of Different Donors Required

Number of Discret Samples from Each Donor

Volume Needed from Each Donor

Additional Details

Container Requirements

Pumping or Screening Date Requirements

Question Title

* 6. Type of Milk Needed


Preterm	Preterm menu
Term	Term menu
Pooled Donor	Pooled Donor menu
Single Donor	Single Donor menu
Pasteurized	Pasteurized menu
Raw Frozen	Raw Frozen menu
Pastuerized Frozen	Pastuerized Frozen menu
Medication Okay	Medication Okay menu

If medications are not okay, please explain.

Question Title

* 7. Documentation (Please note: Milk banks are unable to provide patient identifiers and protected health information.)


Donor Demographics Required	Donor Demographics Required menu
Baby's Gender	Baby's Gender menu
Gestational Age at birth	Gestational Age at birth menu
Age of Mother	Age of Mother menu
Singleton, Multiple	Singleton, Multiple menu

Other (please specify)

Question Title

* 8. Additional Supporting Documentation

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

Question Title

* 9. Research Agreement (Choose all that apply)

I am conducting research that increases understanding of human milk's unique properties and/or its appropriateness for specific medical conditions or populations.

I am conducting a survey/qualitative/epidemiological enquiry related to human milk and/or human milk banking.

I am not conducting research that strives to create a substitute for human milk or contributes to the commercialization of human milk.

My research is not funded by an organization that produces a substitute for human milk or profits from the commercial production of human milk.

I agree to pay the processing fee charged by the milk bank supplying milk for my research.

I agree to acknowledge any relevant milk banks in publications pertaining to this study.

I agree to be in compliance with the above policies.

I agree to provide a brief summary of the status of my research within one year of receipt of HMBANA's research approval letter.

I agree to forward to HMBANA (researchcommittee@hmbana.org) any papers published pertaining to this research.

Question Title

* 10. By writing my name below as a virtual signature and submitting this survey, I agree that I am authorized to commit this project to full compliance with the above policies as much as relevant and possible.