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 donating organs, tissues, or parts to be removed after death. The Donor may also designate the organs to be donated and a recipient.
This optional 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 revoke or amend previous organ donation documents. Press [Ctrl+F1] for more information.
This optional 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
Ohio Organ Donation Form
ORGAOH
The Ohio Organ Donation Form, as suthorized by Ohio law, 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 recive such items.
Enter the name of the individual who is donating organs, tissues, or parts (the "Donor") or edit the information as desired. The gift takes effect at the Donor's death. Use the P.I. Manager to select and paste a record. The name of the Donor will be centered when it is printed.
OOH01
! Information Section (1 of 6)
ORGAN DONATION 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]
OOH02
! Donation Section (2 of 6)
[SELECTIONS LABELED "OPTIONAL" IN THIS FORM ARE ADDITIONS TO THE STANDARD FORM PROVIDED IN OHIO LAW. THE OPTIONS ARE EITHER CONSISTENT WITH OHIO LAW OR OHIO LAW IS SILENT ON THE PARTICULAR OPTION. THE HINTS AND DOCUMENT INFORMATION FURTHER DISCUSS OPTIONAL SECTIONS.]
ANATOMICAL GIFT
!, ! !
In the hope that I may help others upon my death, I hereby give:
for any purpose authorized by law: transplantation, therapy, research, or education.
Enter the name of the individual who is donating organs, tissues, or parts (the "Donor") or edit the information as desired. The gift takes effect at the Donor's death. Use the P.I. Manager to select and paste a record. The name of the Donor will be centered when it is printed.
Enter an X to include this OPTIONAL section that provides the Donor's address. The Donor's address is not included in the standard Ohio form.
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 state or edit the information as desired.
Enter the Donor's zip code or edit the information as desired.
Enter an X if the Donor desires that any authorized donee accept the donation, allowing organs and tissues to be given to individuals or institutions who can use them best. It is generally recommended that most Donors select this option to avoid unduly restricting their donations. Press [Ctrl+F1] for more information.
Enter an X to designate a specific individual or institution to be the donee and to receive the Donor's organs, tissues, or parts. Press [Ctrl+F1] for more information.
Enter the Donee's name or use the P.I. Manager to select and paste a record. CAUTION: Donors should read Document Information on 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 desires that any needed organs, tissues, or parts be donated at the Donor's death. Press [Ctrl+F1] for more information.
Enter an X if the Donor desires that any needed organs, tissues, or parts be donated at the Donor's death EXCEPT for one or two specific organs that the Donor desires NOT to be removed at death.
Enter a description of the specific organs, tissues, or parts that should NOT be removed from the Donor's body at death. For example, "heart" or "eyes".
Enter an X if the Donor desires to specify only selected organs, tissues, or parts to be removed upon the Donor's death.
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 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 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.
OOH03
! Optional Special Limitations Section (3 of 6)
Limitations or special wishes, if any:
Enter an X to include this optional section that allows the Donor to indicate any specific limitations or wishes concerning the donation. Ohio law does not address special limitations. Press [Ctrl+F1] for more information.
Enter a description of the Donor's special wishes. For example, "Use in Ohio, if possible", "Dr. Jones to perform the procedure, if possible", or "for transplantation only".
OOH04
! Optional Revocation or Amendment of Prior Document Section (4 of 6)
[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 that allows the Donor to revoke or amend previous organ donation forms. Ohio law provides for the revocation or amendment of organ donation documents by a signed statement. 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.
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.
OOH05
! Optional Severability Section (5 of 6)
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.
It is recommended that this OPTIONAL section's severability clause be included to prevent one invalid provision from invalidating the entire document. Ohio law does not address severability clauses in forms. If the Donor does not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for more information.
OOH06
! Signature Section (6 of 6)
[DONORS GENERALLY SHOULD BE "COMPETENT" TO EXECUTE A VALID ORGAN DONATION FORM. FOR MORE HELP, DONORS SHOULD ACCESS DOCUMENT INFORMATION REGARDING REQUIRED COMPETENCY TO EXECUTE THE DOCUMENT.]
Signed by the Donor and the following two witnesses in the presence of each other:
Signature of Donor's Representative who signs on the Donor's behalf at the direction of and in the presence of the Donor who is physically unable to sign and in the presence of two witnesses:
[WARNING: One of the two witnesses should be the Donor's parent or guardian if the Donor is under the age of 18.]
[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.]
This is a legal document under the Uniform Anatomical Gift Act or similar laws.
Enter an X to include another individual's signature on behalf of the Donor if the Donor is physically unable to sign the document. Ohio's law allows for an individual to sign on behalf of a Donor who is physically unable to sign the document.
Enter the name of the individual who will sign on behalf of the Donor or use the P.I. Manager to select and paste a record. The name of the individual 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.
Enter the name of the witness or use the P.I. Manager to select and paste a record. This name may be left blank and be completed when the document is signed. If the Donor is under the age of 18, at least one of the witnesses should be the Donor's parent or guardian who consents to the Donation. Press [Ctrl+F1] for more information.
Enter the name of the witness or use the P.I. Manager to select and paste a record. This name may be left blank and be completed when the document is signed. If the Donor is under the age of 18, at least one of the witnesses should be the Donor's parent or guardian who consents to the donation. Press [Ctrl+F1] for more information.
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