OHSU Body Donation Form

OHSU Body Donation Program Enrollment Form

OHSU Body Donation Program

School of Medicine

3181 S.W. Sam Jackson Park Road

Portland, OR 97239-3098

(503) 494-8302

http://www.ohsu.edu/bodydonation/

INFORMATION REGARDING A DONATION TO THE OHSU BODY DONATION PROGRAM

The OHSU Body Donation Program was founded in 1976 as an integral part of medical education and research in the state of Oregon. It is one of the programs under the umbrella service organization, Donate Life Northwest, which includes Pacific Northwest Transplant Bank, Lions Eye Bank of Oregon, American Red Cross Oregon Trail Chapter and Community Tissue Services.

For more than 40 years, the OHSU Body Donation Program has enjoyed a reputation of integrity within the donor community. All donated remains are handled and treated in accordance with the highest ethical standards and in full compliance with federal and state laws and regulations. The OHSU Body Donation Program does not, and will never engage in, profiteering from the use of human remains.

Every year between 200 and 250 altruistic citizens of Oregon and the greater Pacific Northwest donate their bodies and place their trust in us to honor and carry out their final wishes. Our pledge to these remarkable individuals and their families is that we will ensure their remains are used for the advancement of medical education and scientific research throughout Oregon and the greater Pacific Northwest region. The service we offer benefits not only the donors and their families but also the entire community of students and practitioners of medical science.

The OHSU Body Donation program works in close collaboration with the state’s funeral homes. Completion of this donation form is only one part of end-of-life planning. We strongly encourage all donors and donor families discuss their last wishes and make pre-arrangements for any professional services desired with their local funeral director. Although OHSU does offer an annual memorial service, this is not meant to provide final closure for the family but instead to express our student’s appreciation for the invaluable contribution the donor has made to their medical education. Most but not all donors are acceptable to the program at time of death depending on their cause of death and other logistical criteria. The donor’s estate is responsible for all costs associated with the funeral home or cemetery including death scene transport.

If you have any questions, please contact Ginger Wolf, client service manager of the OHSU Body Donation Program at (503) 494-8302, Monday through Friday, 7 a.m. to 4 p.m. If she or one of the staff members are not available, please leave a message or follow instructions on the phone message regarding contacting your local funeral home or transport company.

If you are the donor: By completing and signing this form you are authorizing:

• The donation of your entire body to the Oregon Health & Science University, School of Medicine, for the advancement of medical education and scientific research.

• The Body Donation program will provide a copy of form to the funeral director specified for their records

• Your agent will notify your funeral director as soon as possible after death to allow for processing.

• Your funeral director, upon receipt of your body, to notify the OHSU Body Donation Program and to follow instructions from OHSU regarding embalming requirements.

If you are donating someone else’s body: By completing and signing this form, you are authorizing:

• The donation of the entire body of the person listed below (under “Donor Information”) to the OHSU, School of Medicine, for the advancement of medical education and scientific research.

• The funeral director to notify the OHSU Body Donation Program and to follow instructions from OHSU regarding embalming requirements.

Thank you for your interest in our program. We appreciate it that you would consider giving our program the opportunity to extend your contribution or that of a loved one beyond the grave. This is a gift like no other and its significance is graciously appreciated.

William Cameron, Ph.D., Executive Director, Body Donation Program and Demonstrator for Anatomy for Oregon

ENROLLMENT FORM FOR THE OHSU BODY DONATION PROGRAM

By completing this Enrollment Form, I am authorizing Oregon Health & Science University (“OHSU”) to use my body, or the body listed below for which I have legal authority to determine the disposition of, or transfer it to a qualified institution in the state of Oregon or the Pacific Northwest for anatomical education and/or research.

BODY DONOR INFORMATION

(Please Print Legibly)

Name:

Address: Phone:

City: Zip:

Date of Birth: Birth Place: Sex:

Social Security No.: Veteran:

Service & Serial Number Claim Number

Contact Person*: Phone number:

*This person will serve as the spokesperson for your/the donor’s estate and be contacted by the OHSU Body Donation Program in the event that any questions arise regarding the execution of the donor’s final wishes as described herein.

Donor Status: Married Registered Domestic Partnership Single Domestic Partnership

Name of Spouse/Registered Domestic Partner/Domestic Partner:

AUTHORIZATIONS

(Please read carefully and check where appropriate):

Yes No I have provided my funeral director with an alternate plan should OHSU be unable to accept my remains at the time of death.

Yes No I authorize OHSU to permanently retain my brain for educational coursework.

Yes No Memorial contributions in my name should be made to: “Anatomical Research Fund, OHSU”.

DISPOSITION OF REMAINS

I HEREBY DIRECT AND AUTHORIZE THE RELEASE/DELIVERY OR SHIPMENT OF SAID REMAINS AS FOLLOWS:

(select and initial one of the following four options):

(1) Initial Do not cremate my remains. Release my body to: funeral home.

(I understand there may be a charge for this service at the funeral home; my family or estate will be responsible for payment)

(2) Initial Cremate my remains and deliver to cemetery for the purpose of inurnment.

(I understand there may be a charge for this service at the cemetery; my family or estate will be responsible for payment)

(3) Initial Cremate my remains and bury them at sea as dictated by maritime law.

(I understand that OHSU does not charge for this service)

(4) Initial Cremate my remains and return ashes (OHSU does not charge for this service) to:

Name/Relationship

Street City State Zip

AUTHORIZED SIGNATURE

I acknowledge that I have read (or had read to me) this document in its entirety. I have had the opportunity to ask questions, have had my questions answered, and I fully understand this document. By signing below, I consent to the donation and disposition of the remains as described above. In signing below, I represent myself as the Donor named on this form or as the person with legal authority to make the donation on the Donor’s behalf.

If an Authorized Representative signed above, please provide the following information (please print legibly):

Authorized Representative’s Full Name:

Authorized Representative’s Relationship to Donor:

SIGNATURES OF WITNESSES

Two witnesses must sign this form indicating their willingness to abide by the donor’s wishes to donate his/her body to OHSU. One of the witnesses should be the person to whom we will send an acknowledgment letter of your donation at the time of death and the other witness must be a “disinterested witness”, meaning someone other than:

a spouse, domestic partner, child, parent, sibling, grandchild, grandparent or guardian of the donor; or

an adult who exhibited special care and concern for the donor; or

a representative of an institution (including a hospital, accredited medical school, dental school, college, university) or organization (including an organ procurement organization, eye bank, tissue bank) or other person to whom an anatomical gift could pass to for research or education purposes.

By signing below, I declare that the person who signed this Body Donation Form above is personally known to me, that he/she signed this Body Donation Form in my presence that he/she appeared to be of sound mind and not acting under duress, fraud or undue influence, and that I witnessed his/her signature. Please print the information legibly.