Request a Human Milk Sample


This form should be completed by the Principal Investigator (PI) responsible for overseeing the project and for directing the laboratory and personnel who will receive, use and process the requested specimens.

When submitting a written request for samples:

  1. A separate Mommy’s Milk Specimen Request Form must be submitted for each respective study.
  2. Please be specific about your requirements, including those for storing and handling samples from the time the specimens are collected until they are delivered to your lab (i.e., transport media, refrigeration status, etc.).
  3. Participant identity is confidential. Samples and accompanying clinical data are de-identified and participant identity will not be disclosed under any circumstances.
  4. Principal Investigators must obtain human subjects’ approval from the institution where the work will be  performed followed by Mommy’s Milk Steering Committee approval in order to receive specimens from the Mommy’s Milk Human Milk Research Biorepository. Full or expedited approval, or exemption status for your project must be obtained from the Principal Investigator’s Institutional Review Board (IRB). A copy of the human subjects’ approval documentation should be attached to this form. Specimens/data will not be distributed until notice of your IRB’s action (approval or exemption) is received.
  5. When approval is obtained, a fully executed Material and/or Data Transfer Agreement (MTA) will need to be completed before specimens/data are distributed. The language in the MTA agreement is NOT to be altered.
  6. Periodic progress reports on the study utilizing these samples will be required until study completion, as well as acknowledgement of the Biorepository in all related publications and presentations.

By completing the following application, you agree to the terms above.        

For questions, please contact:

Table 1. Data collection for the Human Milk Biorepository: timing and method of collection

Timing of CollectionMethodInstrument/Question
Breast milk Sample DonationInterview
Heritage/ Lineage
Country of birth
Primary language in household
Educational achievement
Pre-tax household income
Mother of baby job title
Current height of mother
Current weight of mother
Pregnancy History
Number of spontaneous abortions
Number of pregnancy terminations
Breast Feeding Profile
Are you exclusively breast feeding
Quantity and duration of typical breast feeding session
Any supplementation with formula
Quantity of formula supplementation
Any supplementation with solid food
Age of solid food supplementation
Food groups introduced to date
Breast Feeding History
Have you breastfed any other children
Duration of past breastfeeding
Have you ever used a breast pump
Familiarity with a breast pump
Medical History
Family medical history
Personal medical history
Exercise and Frequency
Total hours of sleep in 24 hour period
Offspring Information
Gestational age at delivery
Birth weight, length, OFC
1 minute and 5 minute Apgar scores
Mode of delivery
Current weight, height. OFC
Abnormalities in pediatric exams
Exposure Information (last 14 days)1
Indication, route, dose/unit, frequency, start/stop dates, time last taken
Adverse Reactions in Offspring
Pre-specified reactions to exposures2
Food Frequency Questionnaire
Based upon a 30 day recall
Psychological Health
Edinburgh Postpartum Depression Scale
Perceived Stress Scale-10 item
State-Trait Anxiety Inventory
Post-sample collection assesments3Questionnaire
Offspring neurodevelopment
MacArthur Bates Communicative Development Inventories
Ages and Stages Questionnaire
Infant-Toddler Social and Emotional Assessment
Modified Checklist for Autism in Toddler
Mullen Scales for Early Learning
1 Participants are specifically queried on vitamins/supplements, prescription medications, over the counter medications, birth control, caffeine, alcohol, cigarettes, secondhand smoke, recreational drugs, and illness/fever.
2 Participants are queried specifically about drowsiness, sedation, poor feeding, rash, bruising/bleeding, constipation, diarrhea, bloody stools, fever, low body temperature, restlessness, irritability, poor sleep, high-pitched crying, abnormal movements, abnormal skin color, reflux, eczema, dehydration, or poor weight gain.
3 Neurodevelopmental testing is conducted at child ages of 6 months, 12-16 months, 24-28 months, and 30-36 months. The child is eligible to participate in testing that occurs post-sample collection. If the child misses an assessment, they are still eligible to participate in the next age appropriate assessment.