Midwestern University Body Donation Program 20195 N. 57th 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.
Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
(623) 806-7990 / fax 623-806-7997 [email protected]
Form 1 of 4
PRE-PLANNING DONATION APPLICATION FORM
I, , hereby offer the use of my body after death to Midwestern University Body
Donor Program. Once accepted my body shall be prepared for and used for educational and medical training purposes as
determined by Midwestern University. Such determination may include transporting my body to another approved
educational institution. Upon completion, typically two years after acceptance into the Program, I authorize my body to be
cremated and returned or interred per instructions for final disposition.
I understand that Midwestern University may not be able to accept my body at the time of death, in which case my
durable power of attorney/next of kin/donor agent must make other arrangements for final disposition including
transportation and all associated expenses.
DONOR’S SIGNATURE* Date
Name – PRINTED
Residential Address City or Town State Zip Code
Mailing Address (if different than above) City or Town State Zip Code
Email Address Home Phone # Cell Phone #
Witness Signatures (Two Witness signatures are required in addition to the Donor signature.)
Signature Printed Name Phone # Date
Signature of disinterested witness (Cannot be a family member)
Printed Name Phone # Date
Revised December 2016
Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
(623) 806-7990 / fax 623-806-7997 [email protected]
Form 2 of 4
BODY DONATION GUIDELINES
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
SIGNATURE Date
NAME – PRINTED
Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
(623) 806‐7990 / fax 623‐806‐[email protected]
Form 3 of 4
STATISTICS FORM
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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28
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Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
(623) 806-7990 / fax 623-806-7997 [email protected]
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
Mailing Address City or Town State Zip Code
Email Address Home Phone Cell Phone
Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
(623) 806‐7990 / fax 623‐806‐7997 [email protected]
Revised July 2017
EXCLUSION CRITERIA
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
must be prepared to make alternative disposition arrangements (including all associated expenses) in the event
that donation is declined.
The following is a list of conditions or criteria that will exclude a donation to the program.
persons younger than 18 years of age
death occurring outside the State of Arizona
autopsy (at program's discretion)
excessive trauma/damage to body (at program's discretion)
amputations (at program's discretion)
organ transplants (other than cornea)
unhealed major surgery prior to death
morbid obesity (weight exceeds 300 lbs or at program’s discretion)
height exceeds 6'5"
malnutrition (severe body wasting)
excessive edema
extreme jaundice
infectious diseases that may put program employees and recipients at risk such as:
o hepatitis B & C
o active tuberculosis
o Creutzfeldt‐Jakob
o MRSA/VRSA
o HIV/AIDS
Midwestern University Body Donation Program may decline a donation if the donation exceeds program space
limitations or capacity.
Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
(623) 806-7990 / fax 623-806-7997 [email protected]
FAQ’s
Are there age restrictions for donation?
Arizona Anatomical Gift Act (Chapter 7, Articles 1-3) permits a person who is at least 18 years of age to donate
his/her body to a medical school for educational purposes. There are no upper age limits.
Do I have to pre-apply?
While this is preferred, the donation of another's body to a medical school by the durable power of attorney/next of
kin/donor agent is allowed by Arizona Law.
Can a donation be refused?
Completion of the donor forms is considered to be an application to the donor program. It is not a guarantee that the
donation will be accepted into the program. See Exclusion Criteria. If the donation is refused, the durable power of
attorney/next of kin/donor agent will be responsible for making other arrangements for final disposition including
transportation and all associated expenses.
How will my body be used?
At Midwestern University most body donations are used within health care curricula for anatomical study, but some
are used for research to advance medical and surgical techniques and procedures.
How much time is required to complete the studies?
This will vary according to how the body is used, but generally there is a time lapse of about two years between the
acceptance of the donation into the program and the completion of study.
What happens to the body when study is completed?
The body will be cremated. If requested the program will return the cremains to the person designated to receive
them. If no such request is made, the program will inter the cremains with dignity and respect at a common site. In
such cases, cremains will not be retrieved under any circumstances.
Will my family or other responsible person(s) be sent a report of observations of the study?
No. If at the time of death, a family member or durable power of attorney/next of kin/donor agent has concerns that
might warrant a thorough forensic examination, they should contact the medical examiner or coroner to make
arrangements. If an autopsy is performed, the body cannot be donated. See Exclusion Criteria
Midwestern University Body Donation Program 20195 N. 57th Ave, Glendale, AZ 85308
(623) 806-7990 / fax 623-806-7997 [email protected]
What happens to the body when it's cremated?
Prior to cremation, pacemakers or battery-operated implants must be removed from the body. The body is then
cremated. After cremation is completed, dense tissue such as bones and any metal implants remain. Pacemakers
along with the metal implants are disposed of in a respectful manner. The dense tissues are processed into fine
granules. These fine granules are collectively called cremains. The cremains are placed in a container for final
disposition.
Can I change my mind about donating?
Yes, a donor or durable power of attorney/next of kin/donor agent may revoke an anatomical donation at any time
prior to death by completing a Revocation Form that is available by request from the program.
What if my family disagrees with my wishes to donate after I die?
It is very important to discuss your decision to donate with family members and durable power of attorney/next of
kin/donor agent to make your wishes clear. In the event of a family member or durable power of attorney/next of
kin/donor agent's objection at the time of death, the Body Donation Program will decline the donation.
What happens when I die?
At time of death, durable power of attorney/next of kin/donor agent should contact the Body Donation Program as
soon as possible at 623-806-7990. The Body Donation Program or its representative will accept or decline the
donation based on the Exclusion Criteria. If accepted, the body will be transported to the Body Donation Program
at no cost to the donor's estate as long as death occurs within 30 mile radius of Maricopa County.
Is it possible to have a funeral/memorial service before the body is brought to the donor program?
No, at the time of donation the body is transported to the program. A funeral/memorial service may be held but the
body will not be present.
What is the cost of donation to my family/estate?
If death occurs within a 30 mile radius of Maricopa County and the body is accepted into the program, the program
will assume all costs including cremation and mailing of cremains (if so designated. If death occurs outside of the 30
mile radius and the body is accepted into the program, the family/estate will be responsible for the additional mileage
cost of $3.00 per mile.
How does my durable power of attorney/next of kin/donor agent obtain a death certificate?
All information needed for a death certificate will be filed with Arizona Bureau of Vital Statistics. The durable power
of attorney/next of kin/donor agent must apply for copies of the death certificate and assume associated costs.