This required section provides information regarding an individual's consent to donate or the refusal to donate organs or tissues. There are no entry fields in this section. Press [Ctrl+F1] for more information.
This required section includes the Donor's name and address. The Donor is the individual who is donating organs, tissues, or parts to be removed after the Donor's death. Press [Ctrl+F1] for more information.
This required section allows the Donor to designate which organs, tissues, or parts the Donor desires to donate at the Donor's death. Press [Ctrl+F1] for more information.
This required section allows the Donor to indicate how the donated organs, tissues, or parts are to be used after their removal. Press [Ctrl+F1] for more information.
This required section allows the Donor to indicate specific limitations or wishes concerning the donation of the Donor's organs, tissues, or parts. Press [Ctrl+F1] for more information.
This optional section allows the Donor to designate an individual or institution to receive the donation (the "Donee"). Press [Ctrl+F1] for more information.
This optional section revokes or amends any prior documents and should be completed by any Donor who has previously completed an organ donation form or a "refusal to donate form." Press [Ctrl+F1] for more information.
This required section provides that the inclusion of an invalid request or instruction does not invalidate the other provisions of the document. Press [Ctrl+F1] for more information.
This required section provides for the appropriate signatures on the Organ Donation Form. Press [Ctrl+F1] for more information.
Times New Roman
Arial
Organ Donation Form
ORGANS
The Organ Donation Form allows a person to state his/her intent to make an "anatomical gift" of organs or tissues after the Donor's death, specify how the donated items should be used, and designate who will receive such items.
Enter the Donor's state of residence. The Donor is the individual who is donating organs, tissues and parts. The Donor's selected state will control some of the language in the document. If the Donor is unsure of what state to enter, an attorney should be consulted.
Enter the name of the Donor or edit the information as desired. Use the P.I. Manager to select and paste a record.
ORN01
! Information Section (1 of 9)
ORGAN DONATION FORM
[Important: Ohio and Mississippi require that an organ donation document substantially conform to the form provided in Ohio and Mississippi state law. Residents of Ohio and Mississippi are encouraged to complete the Ohio or Mississippi Form instead of this Form.]
[THIS DOCUMENT ALLOWS INDIVIDUALS TO DONATE THEIR ORGANS, TISSUES, OR PARTS. THE ACTUAL DONATION TAKES EFFECT AFTER THE INDIVIDUAL'S DEATH. THIS DOCUMENT MAY BE USED TO:
* MAKE AN ORGAN DONATION IF AN INDIVIDUAL HAS NEVER BEFORE COMPLETED A DONOR FORM
* MAKE A NEW ORGAN DONATION AND REVOKE OR AMEND A PRIOR DONATION
* MAKE AN ORGAN DONATION IF AN INDIVIDUAL HAS PREVIOUSLY REFUSED TO MAKE AN ORGAN DONATION]
[FOR INDIVIDUALS WHO DO NOT WANT TO BE ORGAN DONORS, THIS PROGRAM PROVIDES THE "REFUSAL TO DONATE FORM". THAT DOCUMENT MAY BE USED TO:
* DOCUMENT THE REFUSAL TO MAKE AN ORGAN DONATION
* REVOKE A PRIOR ORGAN DONATION AND DOCUMENT THE REFUSAL TO MAKE AN ORGAN DONATION]
ORN02
! Donation Section (2 of 9)
[This document has some state specific portions. Enter the state where the Donor currently resides: !.]
I, !, of
!, ! !,
give my organs, tissues, or parts as directed below. This Anatomical Gift will take effect upon my death.
Enter the Donor's state of residence. The Donor is the individual who is donating organs, tissues and parts. The Donor's selected state will control some of the language in the document. If the Donor is unsure of what state to enter, an attorney should be consulted.
Enter the name of the Donor or edit the information as desired. Use the P.I. Manager to select and paste a record.
Enter the Donor's street address or edit the information as desired.
Enter the Donor's extended street address or edit the information as desired.
Enter the Donor's city or edit the information as desired.
Enter the Donor's zip code or edit the information as desired.
ORN03
! Designation of Organs Section (3 of 9)
I give: (initial one of the three options)
! _____ any needed organs, tissues, or parts.
______ any needed organs, tissues, or parts.
! _____ any needed organs, tissues, or parts except: !.
______ any needed organs, tissues, or parts except: !.
! ______ the following organs, tissues, or parts only:
! ______ the following organs, tissues, or parts only: ____________________________________________________.
! _____________________________________________.
Enter an X if the Donor wishes to donate any needed organs, tissues, or parts. The Donor must also initial this choice on the printed form.
Enter an X if the Donor wishes to donate any needed organs, tissues, or parts except for one or two specific organs. The Donor must also initial this choice on the printed form.
Use this space to describe which organs are NOT to be donated. For example, "heart" or "eyes".
Use this space to describe which organs are NOT to be donated. For example, "heart" or "eyes"
Enter an X if the Donor wishes to donate only certain organs, tissues, or parts. This option allows the Donor to state which specific organs, tissues, or parts to donate. The Donor must also initial this choice on the printed form.
Enter an X if the Donor desires to donate the heart at death.
Enter an X if the Donor desires to donate heart valves at death.
Enter an X if the Donor desires to donate lungs at death.
Enter an X if the Donor desires to donate kidneys at death.
Enter an X if the Donor desires to donate the liver at death.
Enter an X if the Donor desires to donate the pancreas at death.
Enter an X if the Donor desires to donate intestines at death.
Enter an X if the Donor desires to donate bone at death.
Enter an X if the Donor desires to donate skin at death.
Enter an X if the Donor desires to donate blood vessels at death.
Enter an X if the Donor desires to donate eyes at death.
Enter an X if the Donor desires to donate musculoskeletal structures (for example, tendons or ligaments) at death.
Enter an X if the Donor desires to donate body fluids at death.
Enter an X if the Donor desires to donate other tissue or cells at death.
Enter an X if the Donor desires to donate a pacemaker at death. California and Georgia provide that a Donor can designate a pacemaker for removal at death.
Enter an X if the Donor desires to specify other organs, tissues, or parts to be donated at the Donor's death.
Enter a description of the organs, tissues, or parts the Donor desires to donate.
ORN04
! Designation of Use Section (4 of 9)
[Note: This section requires that the Donor indicate whether organs can be used for any purpose or only selected purposes. The Donor must initial the selection after printing the form.]
I give my organs, tissues, or parts indicated above to be used for: (initial one of the two options)
_____ any purpose authorized by law.
_____ the following purposes only: (initial all that apply)
_____ transplantation _____ research
_____ therapy _____ education
ORN05
! Required Special Limitations Section (5 of 9)
Limitations or special wishes, if any:
! None.
! [Other]
Enter an X if the Donor has no special limitations or wishes concerning the donation of organs, tissues, or parts. Press [Ctrl+F1] for more information.
Enter an X if the Donor desires to state a specific limitation or special wishes concerning the donation of the Donor's organs, tissues, or parts.
Enter a description of the Donor's special wishes. For example, "Use in Iowa, if possible" or "Dr. Jones to perform the procedure, if possible".
ORN06
! Optional Designation of Donee Section (6 of 9)
My organs, tissues, or parts should be given to:
If the above cannot or does not accept my organs, tissues, or parts I desire that: (initial one)
[It is generally recommended that most Donors select the first option to avoid unduly restricting their donations. The second option should be used with care as it would essentially revoke a donation if the designated donee was unable to accept the organs or tissues for any reason.]
_____ my organs, tissues, or parts be given to any authorized donee.
_____ my organs, tissues, or parts not be donated at my death.
Enter an X to include a designation of an individual or institution to receive the donated organs, tissues, or parts (the "Donee"). If this section is not included, the Donor's organs and tissues will be given to individuals or institutions who can use them. Press [Ctrl+F1] for more information.
Enter the Donee's name or use the P.I. Manager to select and paste a record. CAUTION: For more help, Donors should access Document Information regarding acceptable donees. Only certain individuals and institutions are authorized to accept organs and tissues. Press [Ctrl+F1] for more information.
Enter an X if the Donor knows the Donee's address. It is recommended that the Donor provide as much information as possible. For example, enter an X even if only the Donee's city and state are known.
If known, enter the Donee's street address or edit the information as desired.
If known, enter the Donee's extended street address or edit the information as desired.
If known, enter the Donee's city or edit the information as desired.
If known, enter the Donee's state or edit the information as desired.
If known, enter the Donee's zip code or edit the information as desired.
ORN07
! Optional Revocation or Amendment of Prior Document Section (7 of 9)
[WARNING: A DONOR MAY NEED TO DO MORE THAN COMPLETE THIS OPTIONAL SECTION TO ASSURE A NEW ORGAN DONATION FORM IS HONORED AT A DONOR'S DEATH. FOR EXAMPLE, IF AN ORIGINAL DONOR FORM WAS DELIVERED TO A HOSPITAL OR PHYSICIAN, THEY SHOULD BE NOTIFIED IF IT IS REVOKED. FOR MORE HELP, ACCESS DOCUMENT INFORMATION.]
[WARNING: IF AN INDIVIDUAL WANTS TO REVOKE A PRIOR DONATION AND DOES NOT WANT TO MAKE A NEW DONATION, THE "REFUSAL TO DONATE FORM" SHOULD BE COMPLETED INSTEAD OF THIS DOCUMENT.]
! I revoke any previous document or writing where I donated my organs, tissues, or parts to take effect on my death. I intend for this document to direct the removal and use of my organs, tissues, or parts at my death.
! I amend any previous document or writing where I donated my organs, tissues, or parts to take effect on my death. To the extent this document is inconsistent with or more complete than any previously completed form, I intend for this document to amend or supplement the previous document.
! I hereby revoke any previous document or writing where I indicated my refusal to donate my organs, tissues, or parts after my death.
Enter an X to include this optional section which allows the Donor to revoke or amend previous organ donation or "refusal to donate" documents. Caution: A Donor may need to do more than complete this section to assure a new Form is honored. Press [Ctrl+F1] for more information.
Enter an X if the Donor desires to revoke a previous document or writing where the Donor's organs, tissues, or parts were donated. Caution: If a Donor desires to revoke a donation and does NOT want to make a new donation, the "Refusal to Donate Form" should be completed.
Enter an X if the Donor desires to amend a previous organ donation form. It is recommended that a Donor read Document Information before selecting this option. Press [Ctrl+F1] for more information.
Enter an X if the Donor desires to revoke a previous document indicating the Donor's refusal to donate organs. If a Donor previously completed a "refusal" document and is now making a donation, that Donor should select this option.
ORN08
! Severability Section (8 of 9)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
ORN09
! Signature Section (9 of 9)
[Note: This section requests information on the Donor's age, state of residence, and ability to sign the form. The program will provide the appropriate signature section based on the Donor's selection.]
[DONORS GENERALLY SHOULD BE "COMPETENT" TO EXECUTE A VALID ORGAN DONATION FORM. DONORS SHOULD ACCESS DOCUMENT INFORMATION REGARDING THE REQUIRED COMPETENCY TO EXECUTE THE DOCUMENT.]
! DONOR IS ! (!) YEARS OLD OR OLDER AND ABLE TO SIGN
! DONOR IS ! (!) YEARS OLD OR OLDER AND PHYSICALLY UNABLE TO SIGN
! DONOR IS UNDER THE AGE OF ! (!)
! [Ohio and Wyoming] DONOR IS UNDER THE AGE OF EIGHTEEN (18) AND LIVES IN OHIO OR WYOMING
! [Nevada only] DONOR IS TWELVE (12) YEARS OLD OR OLDER BUT UNDER THE AGE OF EIGHTEEN (18) AND LIVES IN NEVADA
! [Nevada only] DONOR IS UNDER THE AGE OF TWELVE (12) AND LIVES IN NEVADA
Enter an X if the Donor meets the age requirement and is able to sign the form. The program supplies the appropriate age for the state in which the Donor resides. While minors in some states may donate without parental consent, the third option is recommended for most minors.
Enter an X if the Donor meets the age requirement but is physically unable to sign the form. The program supplies the appropriate age for the state in which the Donor resides. Press [Ctrl+F1] for more information.
Enter an X if the Donor is under the age provided. This option provides for parental consent. The program supplies the appropriate age for the state in which the Donor resides. Minors who are completing this document should read Document Information regarding the effectiveness of this form when signed by a minor.
Enter an X if the Donor is under the age of 18 and lives in Ohio or Wyoming.
Enter an X if the Donor is 12 years old or older but under the age of 18 and lives in Nevada.
Enter an X if the Donor is under the age of 12 and lives in Nevada.
I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
! [Illinois] and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection.
! I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
! I witnessed that this document was signed in my presence by the Donor and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
[IT IS GENERALLY RECOMMENDED THAT THE INDIVIDUALS WHO WITNESS A DONOR'S SIGNATURE NOT HAVE A SPECIAL INTEREST IN THE DONATION OF THE DONOR'S ORGANS OR TISSUES. FOR EXAMPLE, A DESIGNATED DONEE WHO IS TO RECEIVE THE ORGANS SHOULD NOT WITNESS THE DONOR'S SIGNATURE.]
Using the format MM/DD/YYYY, enter the Donor's date of birth or edit the information as desired.
The program completes this checkbox if the Donor resides in Illinois. Illinois requires that witnesses certify to certain information about the Donor's state of mind.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Illinois
Illinois
Illinois
ORN11
! Continuation of Signature Section (9 of 9)
I, !, am signing this document at the direction of and in the presence of the Donor, !, who is physically unable to sign and in the presence of two additional witnesses who sign below.
I witnessed that this document was signed in my presence by ! at the direction of and in the presence of the Donor who was physically unable to sign. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
! [Illinois] and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection.
! I witnessed that this document was signed in my presence by ! at the direction of and in the presence of the Donor who was physically unable to sign. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
! I witnessed that this document was signed in my presence by ! at the direction of and in the presence of the Donor who was physically unable to sign and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
[IT IS GENERALLY RECOMMENDED THAT THE INDIVIDUALS WHO WITNESS A DONOR'S SIGNATURE NOT HAVE A SPECIAL INTEREST IN THE DONATION OF THE DONOR'S ORGANS OR TISSUES. FOR EXAMPLE, A DESIGNATED DONEE WHO IS TO RECEIVE THE ORGANS SHOULD NOT WITNESS THE DONOR'S SIGNATURE.]
Enter the name of the person who will sign on behalf of the Donor or use the P.I. Manager to select and paste a record. The name of the representative may be left blank and be completed when the document is signed.
Using the format MM/DD/YYYY, enter the Donor's date of birth or edit the information as desired.
The program completes this checkbox if the Donor resides in Illinois. Illinois requires that witnesses certify to certain information about the Donor's state of mind.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Illinois
Illinois
Illinois
ORN12
! Continuation of Signature Section (9 of 9)
[WARNING: MINOR DONORS SHOULD READ DOCUMENT INFORMATION. MINORS ARE NOT AUTHORIZED TO DONATE THEIR ORGANS IN ALL STATES.]
[Donors under the age of ! (!) should have at least one parent or guardian sign the Organ Donation Form, indicating their consent to the Donor's donation. Although some states, such as Maine, allow individuals 16 years old or older to complete donor forms without parental consent, it is recommended that all minors have a parent or guardian sign the form to increase the likelihood that the form will be honored in any state.]
!, !,
! and !,
, as the
! Parent(s)
! Guardian(s)
of the Donor, !, consent to the Donor's donation of organs, tissues, or parts as directed in this document and sign this document in the presence of the Donor and two additional witnesses who sign below.
I witnessed that this document was signed in my presence by the Donor and the Donor's !. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
! [Illinois] and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection.
! I witnessed that this document was signed in my presence by the Donor and the Donor's !. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
! I witnessed that this document was signed in my presence by the Donor and the Donor's ! and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
[IT IS GENERALLY RECOMMENDED THAT THE INDIVIDUALS WHO WITNESS A DONOR'S SIGNATURE NOT HAVE A SPECIAL INTEREST IN THE DONATION OF THE DONOR'S ORGANS OR TISSUES. FOR EXAMPLE, A DESIGNATED DONEE WHO IS TO RECEIVE THE ORGANS SHOULD NOT WITNESS THE DONOR'S SIGNATURE.]
Enter the name of the parent or guardian who will consent to the minor's donation and sign the form. Use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and be completed when the document is signed.
Enter an X if two parents or guardians will be consenting to a minor Donor's donation.
Enter the name of the second parent or guardian who consents to the minor's donation and will sign the form. Use the P.I. Manager to select and paste a record. The name of the second parent or guardian may be left blank and be completed when the document is signed.
Enter an X if the minor Donor's parent(s) will be consenting to the donation. Minors should have at least one parent or guardian sign the Form, indicating their consent to the minor's donation. Some states prefer that a parent, instead of a guardian, sign the form if possible.
Enter an X if the minor Donor's guardian(s) will be consenting to the donation.
The program completes the checkbox if a second parent or guardian will be signing the form. You may modify the information only by returning to that section.
Using the format MM/DD/YYYY, enter the Donor's date of birth or edit the information as desired.
The program completes this field by transferring the information from a previous section. You may modify the information only by returning to that section.
The program completes this checkbox if the Donor resides in Illinois. Illinois requires that witnesses certify to certain information about the Donor's state of mind.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Nebraska
NINETEEN
EIGHTEEN
Nebraska
Illinois
Illinois
parents
parent
guardians
guardian
Illinois
ORN13
! Continuation of Signature Section (9 of 9)
[Nevada, Ohio and Wyoming]
!, !,
! and !,
, as the
! Parent(s)
! Guardian(s)
of the Donor, !, consent to the Donor's donation of organs, tissues, or parts as directed in this document.
I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
[IT IS GENERALLY RECOMMENDED THAT THE INDIVIDUALS WHO WITNESS A DONOR'S SIGNATURE NOT HAVE A SPECIAL INTEREST IN THE DONATION OF THE DONOR'S ORGANS OR TISSUES. FOR EXAMPLE, A DESIGNATED DONEE WHO IS TO RECEIVE THE ORGANS SHOULD NOT WITNESS THE DONOR'S SIGNATURE.]
WARNING: One of the witnesses should be a parent or guardian who also consents to the donation.
Enter the name of the parent or guardian who will consent to the minor's donation and sign the form. Use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and be completed when the document is signed.
Enter an X if two parents or guardians will be consenting to a minor Donor's donation.
Enter the name of the second parent or guardian who consents to the minor's donation and will sign the form. Use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and be completed when the document is signed.
Enter an X if the minor Donor's parent(s) will be consenting to the donation. Some states prefer that a parent, instead of a guardian, sign the form if possible.
Enter an X if the minor Donor's guardian(s) will be consenting to the donation.
The program completes the checkbox if a second parent or guardian will be signing the form. You may modify the information only by returning to that section.
Using the format MM/DD/YYYY, enter the Donor's date of birth or edit the information as desired.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. At least one of the witnesses should be a parent or guardian who also consents to the donation. Press [Ctrl+F1] for more information.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. At least one of the witnesses should be a parent or guardian who also consents to the donation. Press [Ctrl+F1] for more information.
ORN14
! Continuation of Signature Section (9 of 9)
[Nevada donors under the age of 12]
!, !,
! and !,
, as the
! Parent(s)
! Guardian(s)
of the Donor, !, consent to the Donor's donation of organs, tissues, or parts as directed in this document and hereby sign this document on behalf of the Donor and in the presence of the Donor and two additional witnesses who sign below.
I witnessed that this document was signed in my presence by the Donor's !. I am signing in the presence of and at the direction of the Donor and the Donor's ! and in the presence of the other witness:
[IT IS GENERALLY RECOMMENDED THAT THE INDIVIDUALS WHO WITNESS A DONOR'S SIGNATURE NOT HAVE A SPECIAL INTEREST IN THE DONATION OF THE DONOR'S ORGANS OR TISSUES. FOR EXAMPLE, A DESIGNATED DONEE WHO IS TO RECEIVE THE ORGANS SHOULD NOT WITNESS THE DONOR'S SIGNATURE.]
Enter the name of the parent or guardian who consents to the Minor's donation and will sign on behalf of the minor. Use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and be completed when the document is signed.
Enter an X if two parents or guardians will be consenting to a minor Donor's donation.
Enter the name of the second parent or guardian who consents to the Minor's donation and will sign on behalf of the minor. Use the P.I. Manager to select and paste a record. The name of the parent or guardian may be left blank and be completed when the document is signed.
Enter an X if the minor Donor's parent(s) will be consenting to the donation. Some states prefer that a parent, instead of a guardian, sign the form if possible.
Enter an X if the minor Donor's guardian(s) will be consenting to the donation.
The program completes the checkbox if a second parent or guardian will be signing the form. You may modify the information only by returning to that section.
Using the format MM/DD/YYYY, enter the Donor's date of birth or edit the information as desired.
The program completes this field by transferring the information from a previous section. You may modify the information only by returning to that section.
Enter the name of the FIRST witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Enter the name of the SECOND witness or use the P.I. Manager to select and paste a record. The name of the witness may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
(.txt)