This Document allows individuals to donate their organs, tissues, or parts; the gift to take effect after death. The document may also be used to amend or revoke a previous donation.
Ohio and Mississippi residents are encouraged to complete their state versions of the Organ Donation Form.
Individuals who do NOT want to be organ donors should complete the Refusal to Donate Form.
Any needed organs, tissues, or parts.#| Any needed organs, tissues, orparts except:#|#| The following organs, tissues, or parts only:
ORGANS03
6Which organs or tissues does the Donor wish to donate?
Enter an X if the Donor wishes to donate only certain organs, tissues, or parts. The next question allows the Donor to state which specific organs, tissues, or parts to donate. The Donor must also initial this choice on the printed form.
GWhich of the following organs or tissues does the Donor wish to donate?
ORN03013
SkinBlood vesselsEyesMusculoskeletal structuresBody fluidsOther tissue or cellsPacemaker[Other]
ORGANS03
!#%GWhich of the following organs or tissues does the Donor wish to donate?
ORN03021
{NEXT_?}
Other organs, tissues, or parts:#|
ORGANS03
&>What specific organs or tissues does the Donor wish to donate?
{NEXT_?}
I give my organs, tissues, or parts to be used for: (initial one of the two options on the printed document)
1. _____ any purpose authorized by law.
2. _____ the following purposes only: (initial all that apply)
a. ___ transplantation c. ___ therapy
b. ___ research d. ___ education
ORGANS04
{NEXT_?}
None.#| Special Limitations or Wishes:
ORGANS05
KWhat special limitations or wishes, if any, does the Donor wish to include?
{NEXT_?}
If the designated Donee cannot or does not accept my organs, tissues, or parts, I desire that: (initial one of the following on the printed form)
_____ my organs, tissues, or parts be given to any authorized donee.
_____ my organs, tissues, or parts not be donated at my death.
[It is generally recommended that the first option be selected. 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.]
DWill a Donee be designated to receive the donated organs or tissues?
ORN06001
{NEXT_?}
Revoke a prior documentAmend a prior documentRevoke a "refusal" document
ORGANS07
BWill the Donor revoke or amend a previous organ donation document?
{NEXT_?}
Yes, include the Revocation or Amendment section.
ORGANS07
bDoes the Donor wish to include a section to revoke or amend any previous organ donation documents?
ORN07001
{NEXT_?}
ORGANS08
{NEXT_?}
| The Donor is ABLE to sign theform and | years old or older| The Donor is UNABLE to sign theform and | years old or older| The Donor is under the ageof || Under 18 and lives in OH or WY| The Donor is at least 12 years old but under age 18 and lives in NV| Under age 12 and lives in NV
ORGANS09
"Which option applies to the Donor?
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. Donors should be "competent" to execute a valid form.
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. Donors should generally be "competent" to execute a valid organ donation.
{NEXT_?}
Date of Birth: |
ORGANS10
"What is the Donor's date of birth?
ORN10003
Name: |Name: |
ORGANS10
$What are the names of the witnesses?
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. It is generally recommended that the individuals who witness a Donor's signature not have special interest in the donation.
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. It is generally recommended that the individuals who witness a Donor's signature not have special interest in the donation.
{NEXT_?}
Representative's Name:#|
ORGANS11
>Who is signing the Organ Donation Form on behalf of the Donor?
ORN11005
Date of Birth: |
ORGANS11
"What is the Donor's date of birth?
ORN11007
Name: |Name: |
ORGANS11
$What are the names of the witnesses?
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. It is generally recommended that the individuals who witness a Donor's signature not have special interest in the donation.
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. It is generally recommended that the individuals who witness a Donor's signature not have special interest in the donation.
{NEXT_?}
Name: || [Include second parent/guardian]Name: |
ORGANS12
KWhat is the name of the parent or guardian signing the Organ Donation Form?
ORN12013
Parent(s) will consentGuardian(s) will consent
ORGANS12
0Who is consenting to the minor's organ donation?
ORN12002
Date of Birth: |
ORGANS12
"What is the Donor's date of birth?
ORN12016
Name: |Name: |
ORGANS12
$What are the names of the witnesses?
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. It is generally recommended that the individuals who witness a Donor's signature not have special interest in the donation.
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. It is generally recommended that the individuals who witness a Donor's signature not have special interest in the donation.
{NEXT_?}
Name: || [Include second parent/guardian]Name: |
ORGANS13
KWhat is the name of the parent or guardian signing the Organ Donation Form?
ORN13014
Parent(s) will consentGuardian(s) will consent
ORGANS13
0Who is consenting to the minor's organ donation?
ORN13003
Date of Birth: |
ORGANS13
"What is the Donor's date of birth?
ORN13016
Name: |Name: |
ORGANS13
$What are the names of the witnesses?
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. One of the witnesses should be a parent or guardian who also consented to the donation.
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. One of the witnesses should be a parent or guardian who also consented to the donation.
{NEXT_?}
Name: || [Include second parent/guardian]Name: |
ORGANS14
KWhat is the name of the parent or guardian signing the Organ Donation Form?
ORN14012
Parent(s) will consentGuardian(s) will consent
ORGANS14
0Who is consenting to the minor's organ donation?
ORN14002
Date of Birth: |
ORGANS14
"What is the Donor's date of birth?
ORN14016
Name: |Name: |
ORGANS14
$What are the names of the witnesses?
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. WARNING: At least one of the witnesses should be a parent or guardian who also consents to the donation.
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. WARNING: At least one of the witnesses should be a parent or guardian who also consents to the donation.
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