Free Wisconsin Organ and Tissue Recovery and Assessment - Tissue, DPH 43024 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 43024 (08/06)

STATE OF WISCONSIN Page 1 of 3

WISCONSIN ORGAN AND TISSUE RECOVERY AND ASSESSMENT
Pursuant to Wisconsin Statute Section 157.06 (4m) (e), the following information is to be provided to the Coroner or Medical Examiner's Office at the time of initial request to recover anatomical gifts. Decedent's Name Age Race Sex

Medical Record No.

Type of Donor Brain death Cardiac death

Date and Time of Death

Hospital Death Scene Death

Hospital Name__________________________

Time last known alive if time of death is uncertain:

Briefly describe events leading to death:

Name of Coroner or Medical Examiner Contacted

County of Origin

Date and Time

Name of Investigator (if known)

Date and Time

Coroner or Medical Examiner Case Number

Family member contacted for donation?

Yes

No

Telephone No.

Relationship to donor

Address

ORGANS REQUESTED Heart / Pericardium Lungs TISSUE REQUESTED Upper arm bones Heart for valves; descending thoracic aorta; pericardium Bones of the leg and pelvis Blood vessels (femoral, saphenous, aortic iliac graft) Connective Tissue Eyes / Whole Globe Vertebral bodies Corneas Skin Other: Intestine Lymph Nodes Kidneys (with adrenals) Pancreas Liver Spleen

SIGNATURE ­ Person Completing Form

Print Name and Title

Date Signed

Wisconsin Organ and Tissue Recovery / Assessment DPH 43024 (08/06) Donor Name Medical Record No.

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MEDICAL RECORDS REVIEW
Review of Medical Records to ensure documentation of the following External injuries (including retinal hemorrhage)

If patterned injuries (including bite marks) are present, where on the body are they located?

Internal Injuries Fractures

PHYSICAL FINDINGS
CT scan or MRI of the head? Fresh fractures of long bones, clavicles or ribs? (Particular attention to be paid to metaphysical long bone, clavicle and rib fractures) Retinal hemorrhage or other eye injury? Physical Assessment Key 1. Tattoos 2. Non-therapeutic needle marks 3. Lesions 4. Scars 5. Deformities 6. I.V. Sites or arterial line 7. Contusions 8 Abrasions 9. Surgical Incisions 10. Eye injurries (e.g. Petechiae) 11. Other (List):

SIGNATURE ­ Person Completing Form

Print Name and Title

Date Signed

Wisconsin Organ and Tissue Recovery / Assessment DPH 43024 (08/06) TISSUE RECOVERY AND ASSESSMENT Donor Name Hospital Name Tissue Bank Blood Draw for County Blood Draws Admission Blood Anti-mortem Post-mortem Date and Time Site Donor Number Medical Record No. Location of Recovery Date and Time of Recovery

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Drawn by

TISSUES RECOVERED Upper arm bones Heart for valves; descending thoracic aorta; pericardium

Bones of the leg and pelvis Blood vessels (femoral, saphenous, aortic iliac graft)

Connective Tissue Vertebral bodies

Skin Other

SIGNATURE ­ TECHNICIAN

Print Name

Date Signed

Eye Bank Size of Pupil Right Size of Pupil Left

Donor Number

mm mm Color of Iris Color of Sclera R R L L


2


3 Petechiae


4


5 6 Pupil Gauge (mm) YES 7 NO 8

Vitreous Collection Date and Time

Eye Tissue Recovered Eye / Whole Globe Corneas

SIGNATURE ­ Technician

Print Name

Date Signed