Free Document of Anatomical Gift Authorization for Organ and Tissue Donation, DPH 43025 - Wisconsin


File Size: 37.8 kB
Pages: 2
Date: June 28, 2007
File Format: PDF
State: Wisconsin
Category: Health Care
Author: dhfs/dph/bchp/Organ Donor Program
Word Count: 818 Words, 5,136 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/DPH/dph43025.pdf

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DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 43025 (Rev. 07/07)

STATE OF WISCONSIN Page 1 of 2

DOCUMENT OF ANATOMICAL GIFT AUTHORIZATION FOR ORGAN AND TISSUE DONATION
I / You, (Name of Authorizing Person) the donation of anatomical gifts from (Name of Donor) to benefit humanity as set forth in this Document of Anatomical Gift. This Document is being completed: In-person and witnessed [ ] Copy of document provided If recorded, a copy of this conversation is available upon request. I / You grant permission for the recovery of the following Organs and/or Tissues for purposes of:
Transplantation ORGANS Heart Lungs Liver Kidneys Intestines Pancreas or islet cell Yes Yes Yes Yes Yes Yes Yes No No No No No No No Research N/A N/A N/A N/A N/A N/A Yes No Education and Training Yes Yes Yes Yes Yes Yes No: No No No No No N/A N/A N/A N/A N/A

give permission for

Via telephone and recorded [ ] Copy of document to be mailed.

TISSUES Eyes Corneas Heart for Valves/Pericardium Blood Vessels (Arteries and Veins) Skin BONE AND CONNECTIVE TISSUE OF:
(includes ligaments, tendons & supporting structures)

Upper Arm Lower Arm Lower Extremities Pelvis Ribs Other organ or tissue donation requests: None or Specify:

Yes Yes Yes Yes Yes

No No No No No

N/A N/A N/A N/A N/A

I / You grant permission for: Any testing, examinations, and procedures that may be necessary to determine the medical eligibility of this gift. This includes, but is not limited to, testing for HIV and Hepatitis, removal of adjacent blood vessels for organ transplantation, collection of inguinal/abdominal lymph nodes and spleen, and the collection of blood and biopsy samples for potential recipient compatibility testing. The release of any information, including medical information found within sources to include, but not limited to, hospital records, death certificates, and postmortem examination (autopsy) reports, and information relating to HIV and Hepatitis to determine organ and tissue eligibility. This information may be released to other appropriate agencies.

I / You understand that: Expenses related to the evaluation, maintenance, recovery and placement of the organs and tissues will be paid by the recovery organization(s). Funeral and burial expenses are not the responsibility of the recovery organization(s). The donation process may take several hours to complete, and the release to the funeral home or coroner/medical examiner's office, when applicable, will occur after the recovery process has concluded.

Name of Donor

Date of Birth

ID #

Page 2 of 2

I / You further understand that: I / you may, by this document, limit the use of the bones or tissues, including skin, that are donated or types of organizations that recover, process, or distribute the donation. Donated bones or tissues, including skin, may have numerous uses, including for reconstructive and cosmetic purposes, and multiple organizations, including nonprofit and forprofit organizations, may recover, process, or distribute the donations. In addition, recovered tissues may be distributed internationally. It may be necessary to transport the Donor to another location for the purpose of tissue recovery. I / You specify the following limitations on the use of bones or tissues or on the types of organizations that recover, process, or distribute the donation. None Specific limitations:

Initials of Authorizing Person*

I / You have been given: The option to receive information about how donated organs and/or tissue were used. The opportunity to ask questions about the donation process An explanation of donation options in a language that I / you understand.
Having read this Document of Anatomical Gift in its entirety, or having had it read to me, I / you now give this authorization freely without expectation of any compensation:

Print Name of Authorizing person

SIGNATURE - Authorizing Person*

Date / Time Signed

Relationship to Donor

Street Address

City, State, Zip

Telephone Number

Print Name of Witness

SIGNATURE Witness* SIGNATURE - Person completing form

Date / Time Signed

Print Name of Person completing this form

Date / Time Signed

Name of organization retaining taped consent

*The person completing this form via telephone should initial the space above as appropriate.
The following contact information is provided for use by the authorizing person(s):
University of Wisconsin OPO 450 Science Drive, Suite 220 Madison, Wisconsin 53711-9135 Phone: (866) 894-2676 American Tissue Services Foundation 6064 McKee Road, Suite D Madison, WI 53719 Phone: 888-560-6001 Wisconsin Donor Network OPO 9200 W. Wisconsin Avenue Milwaukee, WI 53226 Phone: (800) 432-5405 Lions Eye Bank of Wisconsin 2302 International Lane, Suite 200 Madison, WI 53704 Phone: (877) 233-2354 Wisconsin Tissue Bank 2801 W. KK River Pkwy, Suite L080 Milwaukee, WI 53215 Phone: (800) 722-8230

Musculoskeletal Transplant Foundation 250 Corporate Drive Madison, WI 53714 Phone: (800) 946-9008 Ext. 2821

RTI Donor Services 6502 Odana Rd. Madison, WI 53719 Phone: (877) 733-3700

Name of Donor

Date of Birth

ID #