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Required format:

yLquUySHudpo5nyemJGmx8TNn2nSUtKUVy458c4gTYwEqZGobxz6HHGXWqroIB5sUQrUf3LFTQnn5ba6n9MIoja3wRaq9mTURGez8MjNKM2ycfbXkmy788pGpriy

Body Donor Evaluation

Returning?

A A A

The purpose of this donor evaluation is to assess the condition of the donor for acceptance into the Donor Program. Once completed and submitted, please have the funeral home contact the Donor Program.

Date of contact

* must provide value

D-M-Y H:M

First name

* must provide value

Middle name

Last name

* must provide value

Social Security Number (SSN)

* must provide value

Date of birth

* must provide value

M-D-Y

Date of death

* must provide value

M-D-Y

First name

* must provide value

Last name

* must provide value

Relationship to donor

* must provide value

Phone number

* must provide value

Approximate height

* must provide value

Approximate weight

* must provide value

Has donor previously had COVID-19?

* must provide value

Yes

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What is the date the donor tested positive of COVID-19?

* must provide value

M-D-Y

Had the donor had a negative COVID test result after recovery?

* must provide value

Yes

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Has the donor received a COVID vaccination or subsequent booster?

* must provide value

Yes

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Has the donor been autopsied?

* must provide value

Yes

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Has the donor been embalmed?

* must provide value

Yes

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Does the donor have any communicable diseases or active infections at time of death?

* must provide value

Yes

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If yes, what?

MRSA

VRE

HIV/AIDS

HEP B

HEP C

C-Diff

CJD

Other

Any type of sepsis?

Septic Shock

Septicemia

Sepsis

Is there any trauma to the body?

* must provide value

Yes

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What type is present?

* must provide value

Advanced Decomposition

Burning

Recent surgical procedure

Suicide

Contraction of the limbs

Accident

Other

Nature/cause of the other trauma

* must provide value

Has the funeral home disinfected the nasal & oral orifices?

* must provide value

Yes

reset

Funeral home name

* must provide value

Phone number

* must provide value

Donor program representative:

To whom at the Donor Program have you spoken with?

* must provide value

Daniel Loesche

Ryan Zwyer

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Upon submission of the Donor Evaluation, it will be reviewed by a Donor Program Representative. Once reviewed, a Donor Program representative will reach back out to you to discuss either the delivery date and time or explain why the donor is not acceptable.

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