Midwestern University Body Donation Program 20195 N. 57 th Ave, Glendale, AZ 85308 (623) 806‐7990 / fax 623‐806‐7997 [email protected]Revised October 2017 GENERAL INSTRUCTIONS Application to the body donation program requires completion of the following six pages. The forms must be initialed, and signed per instructions. DONATION APPLICATION FORM This form requires: 1. Signature of the donor/durable power of attorney/next of kin/donor agent. 2. Signatures and contact information of two witnesses. Witness signatures do not need to be notarized. BODY DONATION GUIDELINES This document informs the applicant about practices and procedures that will be adhered to during donation and subsequent study. Read each section carefully and initial. After reading and initialing each section, sign the form. Initials and signature indicate understanding of and agreement to the guidelines. STATISTICS FORM The information provided in this form will be used for completion and processing of the donor application. DEATH REGISTRATION WORKSHEET (2 pages) Please complete highlighted sections of this worksheet if applicable. We understand that some information is not known until after time of death. This information will be used to complete required government forms at time of death. *Please note: ‐Box #12 ‐Please list month and year of Arizona permanent residency when completing. ‐Boxes #18A thru 18I – This section is to be completed by Next of Kin, Durable Power of Attorney/ Donor Agent. ‐Boxes #24A & #24B ‐ If retired, when completing, please list occupation and industry prior to retirement. If you have any questions about this worksheet, please call our office 623‐806‐7990. FINAL DISPOSITION This form will be used to indicate final disposition of cremains at time of study completion. Application will not be complete and reviewed until all six pages have been completed and submitted. Please contact the Body Donation Program with any questions or for assistance in completing the forms. Mail completed application (all six pages) to Midwestern University Body Donation Program. The forms will be reviewed by program staff. If the application meets program criteria, a donor card will be sent to you via mail.
Transcript
Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
Application to the body donation program requires completion of the following six pages. The forms must be
initialed, and signed per instructions.
DONATION APPLICATION FORM This form requires:
1. Signature of the donor/durable power of attorney/next of kin/donor agent.
2. Signatures and contact information of two witnesses. Witness signatures do not need to be notarized.
BODY DONATION GUIDELINES This document informs the applicant about practices and procedures that will be adhered to during donation and subsequent study. Read each section carefully and initial. After reading and initialing each section, sign the form. Initials and signature indicate understanding of and agreement to the guidelines. STATISTICS FORM The information provided in this form will be used for completion and processing of the donor application. DEATH REGISTRATION WORKSHEET (2 pages) Please complete highlighted sections of this worksheet if applicable. We understand that some information is not known until after time of death. This information will be used to complete required government forms at time of death. *Please note: ‐Box #12 ‐Please list month and year of Arizona permanent residency when completing. ‐Boxes #18A thru 18I – This section is to be completed by Next of Kin, Durable Power of Attorney/ Donor Agent. ‐Boxes #24A & #24B ‐ If retired, when completing, please list occupation and industry prior to retirement. If you have any questions about this worksheet, please call our office 623‐806‐7990. FINAL DISPOSITION This form will be used to indicate final disposition of cremains at time of study completion.
Application will not be complete and reviewed until all six pages have been completed and submitted.
Please contact the Body Donation Program with any questions or for assistance in completing the forms.
Mail completed application (all six pages) to Midwestern University Body Donation Program. The forms will be
reviewed by program staff. If the application meets program criteria, a donor card will be sent to you via mail.
Please read and initial each section. Complete with signature and date.
Application to the donor program does not constitute acceptance into the program. Every effort will be made to accept the donor body; however, Midwestern University Body Donation Program or its representative may, at its sole discretion, decline a donation at the time of death. The durable power of attorney/next of kin/donor agent will be prepared to make alternative disposition arrangements (including all associated expenses) in the event that donation is declined.
Initials ___________
The Program encourages all donors to share their wish for whole body donation with their family members or next of kin/donor agent. Some religious practices do not approve of body embalming and cremation. It is extremely important to discuss and resolve these types of issues with family or durable power of attorney/next of kin/donor before making the decision to donate. If, at the time of death, a family member or next of kin/donor agent raise objections to the donation, the Program will decline the donation. Initials ___________
If the donor has executed a trust or will, living will, durable healthcare power of attorney or related document, the Program encourages the donor to share with any executor/beneficiary or attorney the donor’s intentions regarding Program participation so that those intentions can be properly documented in any will, trust or estate documentation.
Initials ___________
Once accepted, the donated body will be used by the Midwestern University Body Donation Program in a manner determined exclusively by the Program. When making a donation, donors and/or durable power of attorney/next of kin/donor cannot designate the uses to which the body, or parts thereof, will be put nor the persons or entities that will use them. Initials ___________
The donated body may be used for more than one purpose. Parts of the body may be retained for independent study. These parts will be cremated separately and at a different time from that of the rest of the body. Any resulting cremains will be interred in a dignified and respectful manner. These remains will be non-retrievable. Initials ___________
All medical -dental implants and devices that arrive with the body (examples: dentures, bridgework, fillings, ports, shunts, pacemakers, metal fixators and prosthetic joints) will be considered a part of the body and remain with it during study. These devices are not retrievable. Initials ___________
Personal effects received with the body including eyeglasses and hearing aids may be donated. Other items such as clothing or bedding will be discarded. Initials ___________
DONOR/DURABLE POWER OF ATTORNEY OR NEXT OF KIN/DONOR AGENT
Please complete this form electronically or legibly in its entirety. All information is kept confidential.
DONOR’S BRIEF MEDICAL HISTORY & INFORMATION
25. Present state of health:⃝ Poor ⃝ Fair ⃝ Good
26. Check all illnesses that apply.⃝ Heart Disease ⃝ Stroke ⃝ Diabetes ⃝ Kidney Disease ⃝ Liver Disease ⃝ Epilepsy ⃝ Arthritis⃝ High Blood Pressure ⃝ Tuberculosis ⃝ Polio⃝ Cancer Type: _______________ Month/Year of cancer diagnosis _____________
27. List all major operations or surgeries.
28. Check all that apply.⃝ Deformities ⃝ Amputations ⃝ Organ Removal ⃝ Transplants ⃝ Pacemaker ⃝ Non‐ambulatorySpecify any of above: _____________________________________________________________________________
29. History of: (check all that apply)⃝ Active Tuberculosis ⃝ Hepatitis B ⃝ Hepatitis C ⃝ HIV/ AIDS ⃝ Creutzfeldt‐Jakob ⃝ MRSA/ VRSA
30. Weight 31. Height 32. Primary Care Physician’s Name, Phone Number / Fax
DURABLE POWER OF ATTORNEY/ DESIGNATED LEGAL NEXT OF KIN/DONOR AGENT
33a. FIRST NAME 33b. MIDDLE NAME 33c. LAST NAME
33d. Mailing Address 33e. City or Town 33f. State 33g. Zip Code
33h. Email Address 33i. Home Phone 33j. Cell Phone
ALTERNATE CONTACT (This information is important in case we are unable to reach the designated next of kin or donor agent.)
34a. FIRST NAME 34b. MIDDLE NAME 34c. LAST NAME
34d. Mailing Address 34e. City or Town 34f. State 34g. Zip Code
34h. Email Address 34i. Home Phone 34j. Cell Phone
HOW DID YOU HEAR ABOUT US?
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Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
Please complete additional form: Arizona Vital Record Worksheet that is enclosed in this application packet.
Form 4 of 4
FINAL DISPOSITION
I grant Midwestern University Body Donation Program to act as the Authorizing Agent for final disposition of my/or decedent’s body.
I give Midwestern University Body Donation Program permission to retain parts of my body for continued education and study. I understand that upon study completion these body parts will be cremated separately and at a different time from the rest of my body. Any resulting cremated remains will be interred in a dignified and respectful manner. These remains will be non-retrievable.
Please initial your choice to indicate yours or durable power of attorney/next of kin/donor agent’s preference for final disposition:
Return of cremated remains to person designated below. Cremated remains are typically returned within two years from acceptance into program. If not claimed within 90 days of notification, the remains will be interred in a dignified and respectful manner. These remains will be non-retrievable.
No return of cremated remains. Remains will be cremated and interred in a dignified and respectful manner. These remains will be non-retrievable.
DONOR/DURABLE POWER OF ATTORNEY OR NEXT OF KIN/DONOR AGENT SIGNATURE PRINTED NAME DATE
PERSON DESIGNATED TO RECEIVE REMAINS FIRST NAME LAST NAME RELATION TO DONOR
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