Whole Body Medical Education
Resume:
** *. ********* *******, ** ***** 877-***-**** fax 901-***-**** *******@****.*** GEN-038 Set Revised 01/12/24
HOW THE DONATION PROCESS WORKS
1. Become a pre-registered donor or enter the program at the time of death: a. You can become a pre-registered donor by submitting the attached paperwork. b. Call the Genesis Whole Body Donation Program at the time of death at 877-***-****. 2. In cases where an individual other than the donor is authorizing the donation, the state Uniform Anatomical Gift Act provides which individuals may make the gift, in the order specified. Please check with the Genesis Whole Body Donation Program in order to determine who the correct authorizing party is for your state. 3. Donor forms will be reviewed to make sure the donor is currently eligible. Please note that the Genesis Whole Body Donation Program may not be able to accept every willing donor, and may decline to accept a donor who does not meet the requirements for anatomical donations at the time of death. Please contact our office for exclusion criteria. 4. MERI receives and uses the donor for medical education and/or research. 5. The MERI incurs the costs for the following after physical possession of the donor has occurred:
(a) Donor removal and transportation to MERI’s location at 44 S. Cleveland, Memphis, TN;
(b) Death certificate (one);
(c) Final disposition of donor remains;
(d) Return of cremains to family/legal authorizing party or interment in a MERI-designated mausoleum.
6. Cremated remains are available within 6-12 months from the donor’s arrival at the MERI. 7. The family will receive a research letter detailing how the donor helped to further education and research. Thank you for considering whole body donation. Donors working with the Genesis Whole Body Donation Program experience the respect and appreciation deserved by those enabling the critical work of the MERI. Please review the following before you begin filling out our paperwork. Return forms to the Genesis Whole Body Donation Program. If you are a prospective donor please complete the following: Document of Gift
Donor Vital Statistics Information
Medical and Social History
Special Projects (optional)
If you are filling out the paperwork for a loved one please complete the following: Document of Authorization
Donor Vital Statistics Information
Medical and Social History
Special Projects (optional)
It is imperative that the Genesis Whole Body Donation Program is notified immediately upon death. INSTRUCTIONS
Regular business hours are 8:30a.m. to 5:00p.m. central time, Monday through Friday. If death is imminent or has recently occurred, a medical representative (e.g. hospice staff), family member or legally authorized party should CALL to speak with a Genesis representative. There is someone available to accept imminent death or recent death calls 24 hours a day, seven days a week, after hours, on weekends and holidays at 901-***-**** or toll-free at 1-877-***-**** (GIVE). For all other matters, please call during regular business hours. The Genesis Whole Body Donation Program is a program of the Medical Education & Research Institute (MERI). FREQUENTLY ASKED QUESTIONS
Am I eligible for body donation? Most adults are able to make this gift. Please note that the Genesis Whole Body Donation Program accepts no responsibility for any anatomical gift until signed and witnessed donor forms have been received. It is suggested that donors have an alternative plan should they be ineligible at the time of death due to any medical conditions that would prevent them from being a “good teacher.”
Is the Genesis program available in my state? The Genesis Whole Body Donation Foundation program accepts donors whose death occurs in the following states: AL, AR, FL, GA, KS, KY, LA, IA, IL, IN, MS, MO, NC, OH, OK, SC, TN, TX and WV. If the pre-registered donor passes away in another state other than one listed, the donation will be declined. How can I pre-register for the Genesis program? Pre-register by filling out the Genesis donor forms; once received, we will reply by mail and include several donor cards. Donors who are not pre-registered may be accepted at the time of death if they meet current donor criteria. A legal authorizing party may complete paperwork at the time of death. Based upon exclusion criteria, ALL donor final acceptance (pre-registered or at death) is determined at the time of death. Can a person be an organ donor and a Genesis donor? Yes, you may be an organ, eye, or brain donor and a Genesis donor. Can I request which type of research I would like my body donation to benefit? MERI conducts programs in all areas of medicine based on the needs of the sponsors thus we are not able to specify the area of research. As a Genesis donor you can be assured your gift will be part of critical, life-saving training, education, and research that will greatly affect lives throughout the world. What will happen to my personal effects? Any jewelry or other personal effects should be claimed by the next of kin prior to donor transport to the MERI. We will not be responsible for any unclaimed personal effects including, but not limited to, jewelry, medical devices/implants, dentition, etc. All clothing will be discarded. Page 2 of 2
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** GEN-038 Set Revised 01/12/24
FOR DONORS
How soon after death should the Genesis program be contacted? Immediately. It is imperative that Genesis be notified immediately so that proper care may be given to your loved one. See reverse for 24-hour contact information. Who is responsible for transporting the donor to Genesis? Upon notification of death and after Genesis staff have completed screening to confirm acceptance, arrangements will be made by Genesis for transportation of your loved one. You will not have to make any transportation arrangements.
How and when will I receive the death certificates? Effective 01/01/20, Genesis will file for, and provide, one death certificate. We will forward the certificate to you once we receive it. It generally takes four to six weeks for Genesis to receive the death certificate. How long will the donor stay at the MERI? Donors remain at the MERI from six months to a year. What happens during the donor’s stay at the MERI? Donors to the Genesis Whole Body Donation Program participate in programs that enable the critical work of the MERI, including but not limited to the latest surgical techniques and life-saving skills training. This participation may involve dissection and/or anatomical disarticulation or segmentation (e.g. removal of extremities), preservation, photography/imaging, and/or distribution to MERI-approved entities, both for profit and not for profit, for research and educational projects. All donors are treated with the utmost dignity and respect. What happens when the studies on the donor have been completed? Genesis sends a letter detailing the research the donor has made possible. The Genesis staff arranges to have the donor cremated at no cost to the family. Will whole body donation impact my ability to have a funeral? Since the donor must be transported to Genesis so soon after death, whole body donation will prohibit a traditional open casket funeral. Many families choose to have a memorial service either prior to or after receiving their loved one’s ashes.
Is it possible to have the donor’s cremated remains returned? Absolutely. Upon cremation, the remains may be returned to the person designated by the donor. The cremated remains may not include all of the tissues that have been recovered for medical education and research purposes and these may be appropriately medically incinerated. If there is not a designee appointed at the time of death by the donor or by the legal authorizing party, the donor’s cremated remains will be interred in a mausoleum in the Memphis, TN area. If a legal authorizing party/family member requests the cremated remains after that time, the remains will be removed from the mausoleum and returned to the legal authorizing party/family member. FOR FAMILIES
DOCUMENT OF GIFT
I, being of sound mind and body, do
GEN-032 Revised 01/12/24
(Type or print full legal name of Donor - first, middle, maiden & last) hereby make an anatomical gift of my remains upon my death to the Medical Education & Research Institute (MERI), a not-for-profit, 501(c)(3) organization, located at 44 South Cleveland, Memphis, TN, for education and/or research for the ad- vancement of medical, dental, or other health science field or therapy. I understand that this gift may be used for research or the education of medical professionals in surgical and other techniques, and that this use may involve dissection and/or anatomical disarticulation or segmentation (e.g. removal of extremities), preservation, photography/imaging, and/or distribution to MERI-approved entities, both for profit and not-for-profit, for research and educational projects. I understand that acceptance of this gift by MERI is contingent upon medical and suitability criteria at the time of death, and that acceptance is not guaranteed. I understand that neither I, nor my estate, will receive any compensation for this gift. I also understand that MERI will test blood samples for certain communicable diseases including HIV, Hepatitis C, Hepatitis B, and that positive results may be reported to the applicable state, if required by law. I understand that, after confirmation of my eligibility, the MERI is responsible for coordinating my removal and transportation to their location, one death certificate, and final disposition of my remains at no cost to me. Any fees related to the above will be paid by the MERI to the funeral home and/or service firm(s) involved. The MERI incurs no costs for any of the above items if they do not take physical possession of my body due to ineligibility at the time of death or if the donation is rescinded before physical possession occurs.
I understand that the above planned studies are usually completed in one year or less. I also understand that when these studies are complete, the MERI will cremate my body and arrange appropriate disposition of my ashes. I understand the return of cre- mated remains may not include all of the tissues that have been recovered for medical research or educational purposes and that these may be appropriately medically incinerated. I hereby authorize such cremation and disposition. I also understand that upon my cremation, my ashes may be returned to the person that I designate. If I do not appoint a recipient, my cremated remains will be interred in a mausoleum in the Memphis, TN area until a legal authorizing party/family member requests the cremains, at which time the cremated remains will be removed from the mausoleum and returned to the legal authorizing family party/family member.
I further understand that all inquiries, requests, or special instructions about my donation or disposition must be provided to the MERI’s Genesis Whole Body Donation Program, 44 South Cleveland, Memphis, TN, in writing by the legal representative of my estate upon my death.
Bereavement and community resources are available at meri.org. The Vital Statistics and Medical and Social History forms are considered part of this Document of Gift. The Genesis Whole Body Donation Program is a program of the Medical Education & Research Institute (MERI). Page 1 of 2
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** DONOR INFORMATION
Name: Phone:
Street Address: Email:
City/State/Zip:
DONOR SIGNATURE: DATE:
How did you hear about us:
DOCUMENT OF GIFT
I understand that this document is a binding document of gift pursuant to the Uniform Anatomical Gift Act of my state of residence, and that this decision cannot be revoked by any other person. I hereby make this anatomical gift to take place upon my death to the MERI’s Genesis Donation Program for their evaluation and use for medical education and research. In addition, I authorize the release of my personally identifiable health information (medical records) to the MERI in order for it to assess the suitability of my gift for educational and research use. WITNESS INFORMATION #1
WITNESS INFORMATION #2
Name (print): Phone:
Street Address: Email:
City/State/Zip:
Relationship to Donor:
WITNESS SIGNATURE: DATE:
YOU AND YOUR WITNESSES MUST SIGN ON THE SAME DAY FOR FORMS TO BE ACCEPTED You must sign on the same day as your witnesses.
You must sign on the same day as the donor.
(Type or print full legal name of Donor - first, middle, maiden & last)
(Type or print full legal name of Witness - first, middle, maiden & last) Name (print): Phone:
Street Address: Email:
City/State/Zip:
Relationship to Donor:
WITNESS SIGNATURE: DATE:
You must sign on the same day as the donor.
(Type or print full legal name of Witness - first, middle, maiden & last) Page 2 of 2
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** GEN-032 Set Revised 01/12/24
DOCUMENT OF AUTHORIZATION
I,, for humanitarian reasons, do hereby make an anatomical gift of the body of,, Donor, to the Medical Education & Research Institute (MERI), a not-for-profit, 501(c)(3) organization, located at 44 South Cleveland, Memphis, TN, for education or research for the advancement of medical, dental, or other health science field or therapy. I hereby acknowledge that this donation is volunteered without obligation of any kind on the part of the MERI. I understand that this gift may be used for research or the education of medical professionals in surgical and other techniques, and that this use may involve dissection and/or anatomical disarticulation or segmentation (e.g. removal of extremities), preservation, photography/imaging, and/ or distribution to MERI-approved entities, both for profit and not-for-profit, for research and educational projects. I understand that acceptance of this gift by MERI is contingent upon medical and suitability criteria at the time of death, and that acceptance is not guaranteed. I understand that neither I, nor the donor’s estate, will receive any compensation for this gift. I also understand that MERI will test blood samples of the donor for certain communicable diseases including HIV, Hepatitis C, Hepatitis B, and that positive results may be reported to the applicable state, if required by law. I understand that, after confirmation of donor eligibility, the MERI is responsible for coordinating the donor’s removal and transportation to their location, one death certificate, and final disposition of the donor’s remains at no cost to the donor family or legal authorizing party. Any fees related to the above will be paid by the MERI to the funeral home and/or service firm(s) involved. The MERI incurs no costs for any of the above items if they do not take physical possession of the body due to ineligibility at the time of death or if the donation is rescinded before physical possession occurs. I understand that the above planned studies are usually completed in one year or less. I also understand that when these studies are complete, the MERI will cremate the body of the donor and arrange appropriate disposition of the ashes. I understand the return of cremated remains may not include all of the tissues that have been recovered for research or educational purposes, and that these may be appropriately medically incinerated. I hereby authorize such cremation and disposition. I will state the donor’s wishes as to the return of the ashes on the Donor Vital Statistics Information form. If I do not appoint a recipient the donor’s cremated remains will be interred in a mausoleum in the Memphis, TN area until a legal authorizing party/family member requests the cremains, at which time the cremated remains will be removed from the mausoleum and returned to the legal authorizing party/family member.
I further understand that all inquiries, requests, or special instructions about the donation of the above named donor must be provided to the MERI’s Genesis Whole Body Donation Program, 44 South Cleveland, Memphis, TN, in writing by me or the legal representative of the estate of the above named donor. By signing this form, I certify that I am not aware of any objection to this gift by the donor. I am also not aware of any person, other than myself, who has a superior right to authorize this gift under the Anatomical Gift law of the donor’s state. Bereavement and community resources are available at meri.org. The Vital Statistics and Medical and Social History forms are considered part of this Document of Authorization. Page 1 of 2
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** GEN-033 Set Revised 01/12/24
(Type or print full legal name of Legal Authorizing Party - first, middle, maiden & last)
(Type or print full legal name of Donor - first, middle, maiden & last) The Genesis Whole Body Donation Program is a program of the Medical Education & Research Institute (MERI). DOCUMENT OF AUTHORIZATION
LEGAL AUTHORIZING PARTY
Name: Phone:
Street Address: Email:
City/State/Zip:
Relationship to Donor:
LEGAL AUTHORIZING
PARTY SIGNATURE: Date:
How did you hear about us:
WITNESS INFORMATION #1
Name: Phone:
Street Address: Email:
City/State/Zip:
Relationship to Donor:
WITNESS SIGNATURE: DATE:
You must sign on the same day as the Legal Authorizing Party. You must sign on the same day as your witness.
In addition, I authorize the release of personally identifiable health information (medical records) to the MERI in order for it to assess the suitability of their gift for educational and research use.
(Type or print full legal name of Donor - first, middle, maiden & last)
(Type or print full legal name of Legal Authorizing Party - first, middle, maiden & last)
(Type or print full legal name of Witness - first, middle, maiden & last) Page 2 of 2
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** GEN-033 Set Revised 01/12/24
DONOR VITAL STATISTICS INFORMATION
DONOR INFORMATION
Completing this form will help the Medical Education & Research Institute (MERI) make certain that all information is on hand to complete your gift and prepare essential legal documents after death. This information will be disclosed only as necessary to facilitate your donation, and as permitted or required by state law. DONOR’S PERMANENT ADDRESS
DONOR’S PARENTS INFORMATION
First Name: Middle Maiden
Last Age: Sex:
Date of Birth (Month/Day/Year): Social Security Number: Street Address: # of Years at this Address:
City/State/Zip: County:
Within City Limits? Yes No Home Phone (w/area code): US Citizen? Yes No FATHER’S INFORMATION:
First Name: Middle Last
Father’s Place of Birth:
City State
THE FOLLOWING INFORMATION IS REQUIRED TO COMPLETE DEATH CERTIFICATE FOR DONOR MOTHER’S INFORMATION:
First Name: Middle Maiden
Mother’s Place of Birth:
City State
DONOR’S PLACE OF BIRTH
City: State: County:
Foreign Country:
DONOR’S LEGAL AUTHORIZING PARTY (to receive Death Certificate) First Name (print): Middle Last
Street Address:
City/State/Zip:
Relationship to Donor: Cell Phone: Phone:
Email:
Page 1 of 2
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** GEN-036 Set Revised 01/12/24
DONOR VITAL STATISTICS INFORMATION
DONOR’S BACKGROUND INFORMATION
Served in Armed Forces? Yes No If yes, which branch?: Marital Status (check one): Married Never Married Widowed Divorced Donor’s Occupation: Employer:
(type of work during most of life, DO NOT USE RETIRED) Name of Surviving Spouse (if applicable):
If wife, maiden name:
Race - check one or more races to indicate what the donor considers himself/herself to be: White Black or African American Hispanic - please specify: Asian - please specify:
Native American - please specify:
Other:
Education - check the box that best describes the highest degree or level of school completed: 8th Grade or less Associate degree (e.g., AA, AS)
9th-12th grade - no diploma Bachelor’s degree (e.g. BA, BS) High school graduate or GED Master’s degree (e.g. MA, MBA) Some college but no degree Doctorate (e.g. PhD, EdD) or Professional degree (e.g. MD, JD) DISPOSITION OF ASHES
Should donor’s ashes be returned to family or other individual(s)? Yes No If YES, please indicate that person below: First Name (print): Middle Last
Street Address:
City/State/Zip:
Relationship to Donor: Cell Phone: Phone:
Email:
If ashes are NOT to be returned to the family or other individual(s) then the donor’s ashes will be placed in a mausoleum in the Memphis, TN area. Page 2 of 2
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** GEN-036 Set Revised 01/12/24
MEDICAL AND SOCIAL HISTORY
I,, do hereby state that the information below is accurate to the best of my knowledge regarding the health of . The following information may be kept on file at the Medical Education & Research Institute (MERI), 44 South Cleveland, Memphis, TN, for education or research for the advancement of medical, dental, or other health science field or therapy. The MERI cannot accept anatomical donors with Hepatitis B, active syphilis, or Hepatitis C or Tuberculosis (ever in their lifetime), or certain other medical conditions, depending on the review of the Medical Director. In order to provide the most authentic training experience possible, the MERI cannot accept donors who have been embalmed. The MERI is also unable to accept persons who are excessively obese (to be determined on an individual height and weight basis) or under the age of 18 years of age.
As an anatomical donor to the MERI, the following are the donor’s/my most recent surgeries, illnesses, medications, and other therapies that I have knowledge of to the present day. DONOR QUESTIONNAIRE
Past Surgeries (knee, back, hernia repair, pacemaker, etc.): Illnesses (diabetes, high blood pressure, arthritis, cancer, etc.): Has the donor ever had chemotherapy and/or radiation? If so, please list why and date(s) of therapy: Did donor ever smoke? Yes No If yes, how long? Quit? Yes No How long ago? Height: Weight:
ALL FIELDS MUST BE COMPLETED ABOUT THE HEALTH OF THE DONOR. Page 1 of 1
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** GEN-037 Set Revised 01/12/24
(Type or print full legal name of Donor or Legal Authorizing Party - first, middle, maiden & last)
(Type or print full legal name of Donor - first, middle, maiden & last) SPECIAL PROJECTS (optional)
Anatomic gifts to the MERI are used for the advancement of clinical research and hands on medical training. MERI’s Academic Review Board reviews each curriculum to determine its appropriateness for our anatomic donors. From time to time, a request is made to approve the involvement of MERI anatomic donors in special courses and research projects which will lead to improved knowledge, discovery or care in the fields of battlefield medicine, forensic pathology, crime scene investigation, fire investigation, accident safety and other vital scientific endeavors. Only anatomic donors who have an additional special projects gift consent on file will be considered for these special projects. Because the donor’s body will be subjected to more extreme conditions that are likely to result in damage and destruction of all or a large part of the body, and are different in nature, extent and duration from the majority of educational and research uses, donor participation in these projects is voluntary and requires a separate detailed authorization. One example of such a special project is the Fire Investigation course that is used for educating Fire & Arson investigators, Sheriff’s Officers, Police, Prosecutors, Emergency Responders, Coroners, Medical Examiners, and Death Investigators. The courses educate professionals how to properly investigate fire fatalities and helps them determine whether or not the death is a result of a crime or an accident. The training exercises recreate a fire scene (vehicle/house) so that investigators can accurately identify the true cause of death in what survives of the body to reveal vital information if a crime has been committed and give clues to what really happened to the victim(s) hopefully leading to justice and the perpetrator and allowing further such crimes and fatalities to be prevented. These highly specialized courses involve purposeful damage and partial or complete destruction of the body. But without this type of donation, it would be difficult for this knowledge to be taught and new discoveries to be made. Any donor remains would be cremated and returned to the family or interred as requested by the donor/authorizing party. If you give permission for your body to be used for the advancement of scientific endeavors such as fire investigation, battlefield medicine, forensic pathology, or crime investigation please include your signature and date on this form. Thank you for considering this special project participation opportunity. Your signature below authorizes the use of donor’s body in a Special Project, including but not limited to the projects described above.
DONOR CONSENT
Donor fields must be completed to participate in Special Projects. LEGAL AUTHORIZING PARTY (if donor deceased)
Donor Name:
Legal Authorizing Party Name:
Relationship to Donor:
LEGAL AUTHORIZING PARTY SIGNATURE:
Date:
Signature of authorized party is required to participate in Special Projects. Page 1 of 1
44 S. Cleveland Memphis, TN 38104 877-***-**** fax 901-***-**** *******@****.*** GEN-035 Set Revised 01/12/24
Name: Date of Birth:
DONOR SIGNATURE: DATE:
(Type or print full legal name of Donor - first, middle, maiden & last)
(Type or print full legal name of Legal Authorizing Party - first, middle, maiden & last)
(Type or print full legal name of Donor - first, middle, maiden & last)
Contact this candidate