(1) Any person aggrieved by an order of the Authorisation Committee under sub-section (6) of Section 9 or by an order of the Appropriate Authority under sub-section (2) of Section 15 or sub-section (2) of Section 16 of the Act, may, within thirty days from the date of receipt of the order, prefer an appeal to the Central Government in case of the Union territories and respective State Government in case of states.
(2) Every appeal shall be in writing and shall be accompanied by a copy of the order appealed against.
Form 1
For organ or tissue donation from identified living near related donor
(TO BE COMPLETED BY HIM OR HER)
[See Rules 3 and 5(3)(a)]
My full name (proposed donor) is and this is my photograph
| |
Photograph of the Donor (Attested by Notary Public across the photo after affixing) |
To be affixed here. |
My permanent home address is
Tel: ..
My present address for correspondence is
.. .. Tel:
Date of birth . .(day/month/year)
I enclose copies of the following documents: (attach attested photocopy of at least two of following relevant documents to indicate your near relationship):
Ration/Consumer Card number and Date of issue and place: .
and/or
Voter's I-Card number, date of issue, Assembly constituency .
and/or
Passport number and country of issue ..
and/or
Driving License number, Date of issue, licensing authority .
and/or
Permanent Account Number (PAN)
and/or
AADHAAR No.
and/or
Any other valid proof of identity and address reflecting near relationship .
I authorise removal for therapeutic purposes and consent to donate my .
(Name of organ/tissue) to my relative .. (Specify son/daughter/father/mother/brother/sister/grandfather/grandmother/grandson/granddaughter), whose particulars are as follows and name is and who was born on (day/month/year):
Photograph of the Recipient
(Attested by Notary Public across the photo after affixing)
The copies of following documents of recipient are enclosed (attach attested photocopy of at least two relevant documents to indicate your near relationship):
Ration/Consumer Card number and Date of issue and place:
and/or
Voter's I-Card number, date of issue, Assembly constituency .
and/or
Passport number and country of issue:
and/or
Driving License number, Date of issue, licensing authority: ..
and/or
Permanent Account Number (PAN) : .
and/or
AADHAAR No (Issued by Unique Identification Authority of India).
and/or
Any other valid proof of identity and address reflecting near relationship .
I solemnly affirm and declare that:
Sections 2, 9 and 19 of the Transplantation of Human Organs Act, 1994 have been explained to me and I confirm that:
| 1. |
I understand the nature of criminal offences referred to in the sections. |
| 2. |
No payment as referred to in the sections of the Act has been made to me or will be made to me or any other person. |
| 3. |
I am giving the consent and authorisation to remove my . (name of organ/tissue) of my own free will without any undue pressure, inducement, influence or allurement. |
| 4 |
I have been given a full explanation of the nature of the medical procedure involved and the risks involved for me in the removal of my (name of organ)/tissue). That explanation was given by . (name of registered medical practitioner). |
| 5. |
I understand the nature of that medical procedure and of the risks to me as explained by that practitioner. |
| 6. |
I understand that I may withdraw my consent to the removal of that organ at any time before the operation takes place. |
| 7. |
I state that particulars filled by me in the form are true and correct to the best of my knowledge and belief and nothing material has been concealed by me. |
| .. |
.. |
| Date |
Signature of the prospective donor |
| |
(Full Name) |
| Note. To be sworn before Notary Public, who while attesting shall ensure that the person/persons swearing the affidavit(s) signs(s) on the Notary Register, as well. |
Form 2
For organ or tissue donation by living spousal donor
(TO BE COMPLETED BY HIM/HER)
[See Rules 3, 5(3)(a) and 5(3)(d)]
My full name (proposed donor) is .and this is my photograph
| |
Photograph of the Donor (Attested by Notary Public across the photo after affixing) |
To be affixed here. |
My permanent home address is
.. Tel: .
.
My present address for correspondence is ..
.. Tel: .
Date of birth .. (day/month/year)
I authorize removal for therapeutic purposes and consent to donate my (Name of organ) to my husband/wife . whose particulars are as follows and full name is and who was born on (Day/month/year):
| |
Photograph of the Recipient (Attested by Notary Public across the photo after affixing) |
To be here affixed |
I enclose copies of the following documents: (attach attested photocopy of at least two of following relevant documents to indicate the spousal relationship):
Ration/Consumer Card number and Date of issue and place:
and/or
Voter's Identity Card number, date of issue, Assembly constituency
and/or
Passport number and country of issue ..
and/or
Driving License number, Date of issue, licensing authority
and/or
Permanent Account Number (PAN) ..
and/or
AADHAAR No. (issued by Unique Identification Authority of India)
and/or
Any other proof of identity and address establishing spousal relationship .
I submit the following as evidence of being married to the recipient
| (a) |
A certified copy of a marriage certificate |
| |
OR |
| (b) |
An affidavit of a near relative confirming the status of marriage to be sworn before Class-I Magistrate/Notary Public. |
| (c) |
Family photographs |
| (d) |
Letter from Head of Gram Panchayat/Tehsildar/Block Development Officer/Member of Legislative Assembly/Member of Legislative Council (MLC)/Member of Parliament with seal certifying factum and status of marriage. |
| |
OR |
| (e) |
Other credible evidence |
I solemnly affirm and declare that Sections 2, 9 and 19 of the Transplantation of Human Organs Act, 1994 (42 of 1994), have been explained to me and I confirm that
| 1. |
I understand the nature of criminal offences referred to in the sections. |
| 2. |
No payment of money or money's worth as referred to in the sections of the Act has been made to me or will be made to me or any other person. |
| 3. |
I am giving the authorisation to remove my .. (organ) and consent to donate the same, of my own free will without any undue pressure, inducement, influence or allurement. |
| 4. |
I have been given a full explanation of the nature of the medical procedure involved and the risks involved for me in the removal of my .. (organ). That explanation was given by (name of registered medical practitioner). |
| 5. |
I understand the nature of that medical procedure and of the risks to me as explained by that practitioner. |
| 6. |
I understand that I may withdraw my consent to the removal of that organ at any time before the operation takes place. |
| 7. |
I state that particulars filled by me in the form are true and correct to the best of my knowledge and nothing material has been concealed by me. |
| . |
. |
| Date |
Signature of the prospective donor (Full Name) |
| Note. To be sworn before Notary Public, who while attesting shall ensure that the person/persons swearing the affidavit(s) signs(s) on the Notary Register, as well |
Form 3
For organ or tissue donation by other than near relative living donor
(TO BE COMPLETED BY HIM/HER)
[See Rules 3, 5(3)(a) and 5(3)(e)]
My full name is and this is my photograph
| |
Photograph of the Donor (Attested by Notary Public across the photo after affixing) |
To be affixed here. |
My permanent home address is
. Tel: ..
.
My present address for correspondence is .
.. Tel: .
Date of birth .. (day/month/year)
I enclose copies of the following documents: (attach attested photocopy of at least two of following relevant documents to prove your identity):
Ration/Consumer Card number and Date of issue and place:
(Photocopy attached)
and/or
Voter's I-Card number, date of issue, Assembly constituency
(Photocopy attached)
and/or
Passport number and country of issue
(Photocopy attached)
and/or
Driving Licence number, Date of issue, licensing authority .
(Photocopy attached)
and/or
PAN
and/or
AADHAAR No. .
and/or
Other proof of identity and address .
Details of last three years income and vocation of donor (enclose documentary evidence)
I authorize removal for therapeutic purposes and consent to donate my . . (Name of organ/tissue) to a person whose full name is and who was born on (day/month/year) and whose particulars are as follows:
| |
Photograph of the Recipient (Attested by Notary Public across the Photo after affixing) |
To be affixed here. |
(attach attested photocopy of at least two relevant documents to prove identity of recipient)
Ration/Consumer Card number and Date of issue and place:
(Photocopy attached)
and/or
Voter's I-Card number, date of issue, Assembly constituency
(Photocopy attached)
and/or
Passport number and country of issue
(Photocopy attached)
and/or
Driving Licence number, Date of issue, licensing authority .
(Photocopy attached)
and/or
PAN
and/or
AADHAAR No. .
and/or
Other proof of identity and address .
I solemnly affirm and declare that Sections 2, 9 and 19 of the Transplantation of Human Organs Act, 1994 (42 of 1994), have been explained to me and I confirm that
| 1. |
I understand the nature of criminal offences referred to in the Sections. |
| 2. |
No payment of money or money's worth as referred to in the Sections of the Act has been made to me or will be made to me or any other person. |
| 3. |
I am giving the consent and authorisation to remove my .. (name of organ/tissue) of my own free will without any undue pressure, inducement, influence or allurement. |
| 4. |
I have been given a full explanation of the nature of the medical procedure involved and the risks involved for me in the removal of my .. (name of organ/tissue). That explanation was given by (name of registered medical practitioner). |
| 5. |
I understand the nature of that medical procedure and of the risks to me as explained by the practitioner. |
| 6. |
I understand that I may withdraw my consent to the removal of that organ at any time before the operation takes place. |
| 7. |
I state that particulars filled by me in the form are true and correct to the best of my knowledge and nothing material has been concealed by me. |
| .. |
|
| Signature of the prospective donor |
Date |
| (Full Name) |
|
| Note. To be sworn before Notary Public, who while attesting shall ensure that the person/persons swearing the affidavit(s) signs(s) on the Notary Register, as well. |
Form 4
For certification of medical fitness of living donor
(TO BE GIVEN BY THE REGISTERED MEDICAL PRACTITIONER)
[See proviso to Rule 5(3)(b)]
I, Dr . .. possessing qualification of .. registered as medical practitioner at Serial No. . .. by the Medical Council, certify that I have examined Shri/Smt/Km. . S/o, D/o, W/o Shri aged who has given informed consent for donation of his/her . (Name of the organ) to Shri/Smt/Km .. who is a near relative of the donor/other than near relative of the donor and has been approved by the competent authority or Authorisation Committee (as the case may be) and it is certified that the said donor is in proper state of health, not mentally challenged* and is medically fit to be subjected to the procedure of organ or tissue removal.
| Place: . |
|
|
| Date: . |
|
Signature of Doctor Seal |
| To be affixed (pasted) here |
|
To be affixed (pasted) here |
| Photograph of the Donor (Attested by doctor) |
|
Photograph of the recipient (Attested by the doctor) |
The signatures and seal should partially appear on photograph and document without disfiguring the face in photograph
* In case of doubt for mentally challenged status of the donor, the Registered Medical Practitioner may get the donor examined by psychiatrist.
Form 5
For certification of genetic relationship of living donor with recipient
(TO BE FILLED BY THE HEAD OF PATHOLOGY LABORATORY CERTIFYING RELATIONSHIP)
[See Rules 5(3)(c) and 18(3)]
I, Dr./Mr./Mrs/Miss. .. working as . at and possessing qualification of certify that Shri/Smt/Km .. S/o, D/o, W/o Shri/Smt aged . .. .. .. . the donor and Shri/Smt . . S/o, D/o, W/o Shri/Smt .. aged the prospective recipient of the organ to be donated by the said donor are related to each other as brother/sister/mother/father/son/daughter, grandmother, grandfather, grandson and granddaughter as per their statement. The fact of this relationship has been established/not established by the results of the tests for DNA profiling. The results of the tests are attached.
| |
Signature |
| |
(To be signed by the Head of the Laboratory) |
| Place |
Seal |
| Date . |
|
Form 6
For spousal living donor
(TO BE FILLED BY COMPETENT AUTHORITY* AND AUTHORISATION COMMITTEE, OF THE HOSPITAL OR DISTRICT OR STATE IN CASE OF FOREIGNERS)
[See Rule 18(2)]
I, Dr/Mr/Mrs/Miss . .. possessing qualification of registered as medical practitioner at serial No. by the . . Medical Council, certify that
Mr . S/o aged .resident of .and Mrs D/o, W/o aged ..resident of .. are related to each other as spouse according to the statement given by them and their statement has been confirmed by means of following evidence before effecting the organ removal from the body of the said Shri/Smt/ . (Applicable only in the cases where considered necessary).
OR
In case the Clinical condition of Shri/Smt mentioned above is such that recording of his/her statement is not practicable, reliance will be placed on the documentary evidence(s). (mention documentary evidence(s) here) ..
a. Marriage certificate indicate date of marriage
b. Marriage photographs
c. Date when transplantation was advised by the hospital (to be compared with duration of marriage):
d. Number and age of children and their birth certificates
e. Any other document
Signature of competent authority*/Authorisation committee in case of foreigners along with Seal/Stamp
Place
Date .
*Director or Medical Superintendent or In-charge of the hospital or the internal committee of the hospital formed for the purpose as defined under the rules of Transplantation of Human Organ Act, 1994(42 of 1994).
Form 7
For organ or tissue pledging
(TO BE FILLED BY INDIVIDUAL OF AGE 18 YEAR OR ABOVE)
[See Rule 5(4)(a)]
ORGAN(S) AND TISSUE(S) DONOR FORM
(TO BE FILLED IN TRIPLICATE)
Registration Number (To be allotted by Organ Donor Registry) . .
I S/o, D/o, W/o aged and date of birth resident of in the presence of persons mentioned below hereby unequivocally authorise the removal of following organ(s) and/or tissue(s), from my body after being declared brain stem dead by the board of medical experts and consent to donate the same for therapeutic purposes.
| Please tick as applicable |
(Following tissues can also be donated after brain stem death as well as cardiac death) |
| Heart |
|
Corneas/Eye Balls |
|
| Lungs |
|
Skin |
|
| Kidneys |
|
Bones |
|
| Liver |
|
Heart Valves |
|
| Pancreas |
|
Blood Vessels |
|
| Any Other Organ (Pl. specify) |
. |
Any other Tissue (Pl. specify) |
|
| All Organs |
|
All Tissues |
|
| My blood group is (if known) |
| Signature of Pledger |
| Address for correspondence |
| Telephone No |
| E-mail : |
| Dated: |
(Note. In case of online registration of pledge, one copy of the pledge will be retained by pledger, one by the institution where pledge is made and a hard copy signed by pledger and two witnesses shall be sent to the nodal networking organisation.)
(Signature of Witness 2)
1. Shri/Smt./Km S/o, D/o, W/o aged resident of Telephone No E-mail: .
(Signature of Witness 1)
1. Shri/Smt./Km .. S/o, D/o, W/o aged resident of . Telephone No. E-mail: .. is a near relative to the donor as
Dated
Place .
Note: (i) Organ donation is a family decision. Therefore, it is important that you discuss your decision with family members and loved ones so that it will be easier for them to follow through with your wishes.
(ii) One copy of the pledge form/pledge card to be with respective networking organisation, one copy to be retained by institution where the pledge is made and one copy to be handed over to the pledger.
(iii) The person making the pledge has the option to withdraw the pledge.
Form 8
For Declaration cum consent
(TO BE FILLED BY NEAR RELATIVE OR LAWFUL POSSESSOR OF BRAIN-STEM DEAD PERSON)
[See Rules 5(1)(b), 5(4)(b) and 5(4)(d)]
DECLARATION AND CONSENT FORM
I . S/o, D/o, W/o aged resident of .in the presence of persons mentioned below, hereby declare that:
1. I have been informed that my relative (specify relation) . S/o, D/o, W/o ..aged .has been declared brain-stem dead/dead.
2. To the best of my knowledge (Strike off whichever is not applicable):
a. He/She. (Name of the deceased) .. had/had not, authorised before his/her death, the removal of .(Name of organ/tissue/both) of his/her body after his/her death for therapeutic purpose. The documentary proof of such authorisation is enclosed/not available.
b. He/She. (Name of the deceased) ..had not revoked the authority as at No. 2(a) above (If applicable).
c. There are reasons to believe that no near relative of the said deceased person has objection to any of his/her organs/tissue being used for therapeutic purposes.
3. I have been informed that in the absence of such authorisation, I have the option to either authorise or decline donation of organ/tissue/both including eye/cornea of .. (Name of the deceased) for therapeutic purposes. I also understand that if corneas/eyes are not found suitable for therapeutic purpose, then may be used for education/research.
4. I hereby authorise/do not authorize removal of his/her body organ(s) and/or tissue(s), namely (Any organ and tissue/Kidney/Liver/Heart/Lungs/Intestine/Cornea/Skin/Bone/Heart Valves/Any other; please specify) . for therapeutic purposes. I also give permission for drawing of a blood sample for serology testing and am willing to share social/behavioural and medical history to facilitate proper screening of the donor for safe transplantation of the organs/tissues.
| Date . |
Signature of near relative/person in lawful possession of the dead body, and address for correspondence*. |
| Place |
Telephone No E-mail: |
*In case of the minor the declaration shall be signed by one of the parent of the minor or any near relative authorised by the parent. In case the near relative or person in lawful possession of the body refuses to sign this form, the same shall be recorded in writing by the Registered Medical Practitioner on this Form.
(Signature of Witness 1)
1. Shri/Smt/Km S/o, D/o, W/o . aged .. resident of Telephone No .. E-mail: ..
(Signature of Witness 2)
1. Shri/Smt/Km S/o, D/o, W/o . aged .. resident of Telephone No .. E-mail: ..
Form 9
For unclaimed body in a hospital or prison
(TO BE COMPLETED BY PERSON IN LAWFUL POSSESSION OF THE UNCLAIMED BODY)
[See Rule 5(1)(b)]
I S/o, D/o, W/o . aged . resident of having lawful possession of the dead body of Shri/Smt/Km . S/o, D/o, W/o aged resident of .and having known that no person has come forward to claim the body of the deceased after 48 hours of death and there being no reason to believe that any person is likely to come to claim the body I hereby, authorise removal of his/her body organ(s) and/or tissue(s), namely ..for therapeutic purposes.
Signature, Name, designation and Stamp of person in lawful possession of the dead body.
Dated .. Place
Address for correspondence .
.
Telephone No. ..E-mail
(Signature of Witness 1)
1. Shri/Smt./Km S/o, D/o, W/o . aged .. resident of Telephone No .. E-mail: ..
(Signature of Witness 2)
1. Shri/Smt./Km S/o, D/o, W/o . aged .. resident of Telephone No .. E-mail: ..
Form 10
For certification of brain stem death
(TO BE FILLED BY THE BOARD OF MEDICAL EXPERTS CERTIFYING BRAIN-STEM DEATH)
[See Rules 5(4)(c) and 5(4)(d)]
We, the following members of the Board of medical experts after careful personal examination hereby certify that Shri/Smt/Km aged about . son of/wife of/daughter of .. Resident of . is dead on account of permanent and irreversible cessation of all functions of the brain-stem. The tests carried out by us and the findings therein are recorded in the brain-stem death Certificate annexed hereto.
| 1. |
R.M.P. In-charge of the Hospital In which brain-stem death has occurred. |
2. |
R.M.P. nominated from the panel of Names sent by the hospitals and approved by the Appropriate Authority |
| 3. |
Neurologist/Neurosurgeon |
4. |
R.M.P. treating the aforesaid deceased person |
| |
(where Neurologist/Neurosurgeon is not available, any Surgeon or Physician and Anaesthetist or Intensivist, nominated by Medical Administrator In-charge from the panel of names sent by the hospital and approved by the Appropriate Authority shall be included) |
BRAIN-STEM DEATH CERTIFICATE
| (A) |
PATIENT DETAILS . |
| 1. |
Name of the patient: |
Mr/Ms |
| |
S.O./D.O./W.O. |
Mr/Ms |
| |
|
Sex Age |
| 2. |
Home Address: |
|
| 3. |
Hospital Patient Registration Number (CR No.): |
|
| 4. |
Name and Address of next of kin or person |
|
| |
responsible for the patient |
|
| |
(if none exists, this must be specified) |
|
| 5. |
Has the patient or next of kin agreed |
|
| |
to any donation of organ and/or tissue? |
|
| 6. |
Is this a Medicolegal Case? |
Yes .. No . |
| (B) |
PRE CONDITIONS: |
| 1. |
Diagnosis: |
Did the patient suffer from any illness or accident that led to irreversible brain damage? |
| |
Specify detail |
| |
|
| |
|
| |
Date and time of accident/onset of illness |
| |
Date and onset of non-reversible coma |
| 2. |
Findings of Board of Medical Experts: |
| |
First Medical Examination Second Medical Examination |
| (1) |
The following reversible causes of coma have been excluded: |
| |
Intoxication (Alcohol) |
| |
Depressant Drugs |
| |
Relaxants (Neuromuscular blocking agents) |
| |
Primary Hypothermia |
| |
Hypovolaemic shock |
| |
Metabolic or endocrine disorders |
| |
Tests for absence of brain-stem functions |
| (2) |
Coma |
| (3) |
Cessation of spontaneous breathing |
| (4) |
Pupillary size |
| (5) |
Pupillary light reflexes |
| (6) |
Doll's head eye movements |
| (7) |
Corneal reflexes (Both sizes) |
| (8) |
Motor response in any cranial nerve distribution, any responses to stimulation of face, limb or trunk. |
| (9) |
Gag reflex |
| (10) |
Cough (Tracheal) |
| (11) |
Eye movements on caloric testing bilaterally. |
| (12) |
Apnoea tests as specified. |
| (13) |
Were any respiratory movements seen? |
| |
| Date and time of first testing: |
| Date and time of second testing: |
This is to certify that the patient has been carefully examined twice after an interval of about six hours and on the basis of findings recorded above,
Mr./Ms is declared brain-stem dead.
Date:
Signatures of members of Brain Stem Death (BSD) Certifying Board as under:
| 1. |
Medical Administrator In-charge of the hospital |
2. |
Authorised specialist |
| 3. |
Neurologist/Neurosurgeon |
4. |
Medical Officer treating the Patient |
| Note. |
| I. |
Where Neurologist/Neurosurgeon is not available, then any Surgeon or Physician and Anaesthetist or Intensivist, nominated by Medical Administrator In-charge of the hospital shall be the member of the board of medical experts for brain-stem death certification. |
| II. |
The minimum time interval between the first and second testing will be six hours in adults. In case of children 6 to 12 years of age, 1 to 5 years of age and infants, the time interval shall increase depending on the opinion of the above BSD experts. |
| III. |
No. 2 and No. 3 will be co-opted by the Administrator In-charge of the hospital from the Panel of experts (Nominated by the hospital and approved by the Appropriate Authority). |
Form 11
Application for Approval of Transplantation from Living Donor
(TO BE COMPLETED BY THE PROPOSED RECIPIENT AND THE PROPOSED LIVING DONOR)
[See Rules 5(3)(d), 5(3)(e) and 10]
| |
|
|
|
| |
|
|
|
| |
To be self attested across the affixed photograph without disfiguring face |
|
To be self attested across the affixed photograph without disfiguring face |
| |
Photograph of the Donor |
|
Photograph of the recipient |
Whereas I S/o, D/o, W/o, Shri/Smt. aged .. residing at . have been advised by my doctor that I am suffering from .. and may be benefited by transplantation of . into my body.
And whereas I S/o, D/o, W/o, Shri/Smt. . aged .. residing at . by the following reason(s)
(a) by virtue of being a near relative i.e. .
(b) by reason of affection/attachment/other special reason as explained below
I would therefore like to donate my (name of the organ) . to Shri/Smt We . and ..
(Donor)(Recipient)
hereby apply to competent authority/Authorisation Committee for permission for such transplantation to be carried out.
We solemnly affirm that the above decision has been taken without any undue pressure, inducement, influence or allurement and that all possible consequences and options of organ transplantation have been explained to us.
Instructions for the applicants
| 1. |
Form 11 must be submitted along with the completed Form 1 or Form 2 or Form 3 as may be applicable. |
| 2. |
The applicable Form i.e. Form 1 or Form 2 or Form 3 as the case may be, should be accompanied with all documents mentioned in the applicable form and all relevant queries set out in the applicable form must be adequately answered. |
| 3. |
Completed Form 5 must be submitted along with the laboratory report. |
| 4. |
The doctor's advice recommending transplantation must be enclosed with the application. |
| 5. |
In addition to above, in case the proposed transplant is between unrelated persons, appropriate evidence of vocation and income of the donor as well as the recipient for the last three years must be enclosed with this application. It is clarified that the evidence of income does not necessarily mean the proof of income tax returns, keeping in view that the applicant(s) in a given case may not be filing income tax returns. |
| 6. |
The application shall be accepted for consideration by the competent authority/Authorisation Committee only if it is complete in all respects and any omission of the documents or the information required in the forms mentioned above, shall render the application incomplete. |
| 7. |
When the donor is unrelated and the donor and/or recipient belong to a State/Union Territory other than the State/Union Territory, where the transplant is intended to take place, then the Tehsildar or the officer authorised for the purpose of the domicile state of the donor or recipient as the case may be, would provide the verification certificate of domicile of donor/recipient as the case may be as per Form 20. The approval for transplantation would be considered by the authorisation committee of the State/District/hospital (as the case may be) where the transplantation is intended to be done. Such verification Certificate will not be required for near relatives including cases involving swapping of organs (permissible between near relatives only). |
| We have read and understood the above instructions. |
| Signature of the Prospective Donor |
Signature of Prospective Recipient |
| Address for correspondence: |
Address for correspondence: |
| Date: |
Date: |
| Place: |
Place: |
Form 12
Application for Registration of Hospital to carry out Organ or Tissue Transplantation other than Cornea
(TO BE FILLED BY HEAD OF THE INSTITUTION)
[See rule 24(1)]
To
The Appropriate Authority for organ transplantation ..
(State or Union territory)
We hereby apply to be registered as an institution to carry out organ/tissue transplantation. Name(s) of organ (s) or tissue (s) for which registration is required .
The required data about the facilities available in the hospital are as follows
| (A) |
HOSPITAL: |
|
| 1. |
Name: |
|
| 2. |
Location: |
|
| 3. |
Government/Private: |
|
| 4. |
Teaching/Non-teaching: |
|
| 5. |
Approached by: |
|
| |
|
Road: |
Yes |
No |
| |
|
Rail: |
Yes |
No |
| |
|
Air: |
Yes |
No |
| 6. |
Total bed strength: |
|
| 7. |
Name of the disciplines in the hospital: |
| 8. |
Annual budget: |
| 9. |
Patient turnover/year: |
| (B) |
SURGICAL FACILITIES: |
| 1. |
No. of beds: |
| 2. |
No. of permanent staff members with their designation: |
| 3. |
No. of temporary staff with their designation: |
| 4. |
No. of operations done per year: |
| 5. |
Trained persons available for transplantation (Please specify Organ for transplantation): |
| (C) |
MEDICAL FACILITIES: |
| 1. |
No. of beds: |
| 2. |
No. of permanent staff members with their designation: |
| 3. |
No. of temporary staff members with their designation: |
| 4. |
Patient turnover per year: |
| 5. |
Trained persons available for transplantation (Please specify Organ for transplantation): |
| 6. |
No. of potential transplant candidates admitted per year: |
| (D) |
ANAESTHESIOLOGY: |
| 1. |
No. of permanent staff members with their designations: |
| 2. |
No. of temporary staff members with their designations: |
| 3. |
Name and No. of operations performed: |
| 4. |
Name and No. of equipments available: |
| 5. |
Total No. of operation theatres in the hospital: |
| 6. |
No. of emergency operation theatres: |
| 7. |
No. of separate transplant operation theatre: |
| (E) |
I.C.U./H.D.U. Facilities: |
| 1. |
I.C.U./H.D.U. Facilities: Present Not present |
| 2. |
No. of I.C.U. and H.D.U. beds: |
| 3. |
Trained |
| |
Nurses: |
| |
Technicians: |
| 4. |
Name of equipment in I.C.U. |
| (F) |
OTHER SUPPORTIVE FACILITIES: |
| Data about facilities available in the hospital: |
| (F1) |
LABORATORY FACILITIES: |
| 1. |
No. of permanent staff with their designations: |
| 2. |
No. of temporary staff with their designations: |
| 3. |
Names of the investigations carried out in the Department: |
| 4. |
Name and number of equipments available: |
| (F2) |
IMAGING FACILITIES: |
| 1. |
No. of permanent staff with their designations: |
| 2. |
No. of temporary staff with their designations: |
| 3. |
Names of the investigations carried out in the Department: |
| 4. |
Name and number of equipments available: |
| (F3) |
HAEMATOLOGY FACILITIES: |
| 1. |
No. of permanent staff with their designations: |
| 2. |
No. of temporary staff with their designations: |
| 3. |
Names of the investigations carried out in the Department: |
| 4. |
Name and number of equipments available: |
| (F4) |
BLOOD BANK FACILITIES (In-house or access): Yes No |
| (F5) |
DIALYSIS FACILITIES: Yes .. No .. |
| (F6) |
Transplant coordinators (Eye Donation Counsellors, in case of Cornea Transplantation): |
| Yes |
No |
| |
Number Posted: |
| |
Number Trained |
| (F7) |
OTHER SUPPORTIVE EXPERT PERSONNEL: |
| 1. |
Nephrologist |
Yes/No |
| 2. |
Neurologist |
Yes/No |
| 3. |
Neurosurgeon |
Yes/No |
| 4. |
Urologist |
Yes/No |
| 5. |
G.I. Surgeon |
Yes/No |
| 6. |
Paediatrician |
Yes/No |
| 7. |
Physiotherapist |
Yes/No |
| 8. |
Social Worker |
Yes/No |
| 9. |
Immunologists |
Yes/No |
| 10. |
Cardiologist |
Yes/No |
| 11. |
Respiratory physician |
Yes/No |
| 12. |
Others . |
Yes/No |
| The abovesaid information is true to the best of my knowledge and I have no objection to any scrutiny of our facility by authorised personnel. A Bank Draft/cheque of Rs 10,000 (for new registration) and Rs 5000 (for renewal) in favour of .is enclosed. |
| Sd/ Head of the Institution |
Form 13
Application for Registration of Hospital to carry out Organ/Tissue retrieval other than Eye/Cornea Retrieval
(TO BE FILLED BY HEAD OF THE INSTITUTION)
[See Rule 24(1)]
Note: Retrieval Hospitals may also be identified based on predefined criteria and registered as retrieval hospital by the appropriate authority.
To
The Appropriate Authority for organ transplantation
(State or Union territory)
We hereby apply to be registered as an institution to carry out organ/tissue retrieval.
The required data about the facilities available in the hospital are as follows
| (A) |
HOSPITAL: |
|
| 1. |
Name: |
|
| 2. |
Location: |
|
| 3. |
Government/Private: |
|
| 4. |
Teaching/Non-teaching: |
|
| 5. |
Approached by: |
|
| |
|
Road: |
Yes |
No |
| |
|
Rail: |
Yes |
No |
| |
|
Air: |
Yes |
No |
| 6. |
Total bed strength: |
| 7. |
Name of the disciplines in the hospital: |
| 8. |
Annual budget: |
| 9. |
Patient turnover/year: |
| (B) |
SURGICAL FACILITIES: |
| 1. |
No. of beds: |
| 2. |
No. of permanent staff members with their designation: |
| 3. |
No. of temporary staff with their designation: |
| 4. |
No. of operations done per year: |
| 5. |
Trained persons available for retrieval (Please specify Organ and/or tissue for retrieval): |
| (C) |
MEDICAL FACILITIES: |
| 1. |
No. of beds: |
| 2. |
No. of permanent staff members with their designation: |
| 3. |
No. of temporary staff members with their designation: |
| 4. |
Patient turnover per year: |
| 5. |
Trained persons available for retrieval (Please specify Organ and/or tissue for retrieval): |
| 6. |
No. of critical trauma cases admitted per year. |
| 7. |
No. of brain stem death declared per year. |
| (D) |
ANAESTHESIOLOGY: |
| 1. |
No. of permanent staff members with their designations: |
| 2. |
No. of temporary staff members with their designations: |
| 3. |
Name and No. of operations performed: |
| 4. |
Name and No. of equipments available: |
| 5. |
Total No. of operation theatres in the hospital: |
| 6. |
No. of emergency operation theatres: |
| 7. |
No. of separate retrieval operation theatre: |
| (E) |
I.C.U./H.D.U. FACILITIES: |
| 1. |
I.C.U./H.D.U. facilities: Present Not present . |
| 2. |
No. of I.C.U. and H.D.U. beds: |
| 3. |
Trained |
| |
Nurses: |
| |
Technicians: |
| 4. |
Name of equipment in I.C.U. |
| (F) |
OTHER SUPPORTIVE FACILITIES: |
| Data about facilities available in the hospital: |
| (F1) |
LABORATORY FACILITIES: |
| 1. |
No. of permanent staff with their designations: |
| 2. |
No. of temporary staff with their designations: |
| 3. |
Names of the investigations carried out in the Department: |
| 4. |
Name and number of equipments available: |
| (F2) |
IMAGING FACILITIES: |
| 1. |
No. of permanent staff with their designations: |
| 2. |
No. of temporary staff with their designations: |
| 3. |
Names of the investigations carried out in the Department: |
| 4. |
Name and number of equipments available: |
| (F3) |
HAEMATOLOGY FACILITIES: |
| 1. |
No. of permanent staff with their designations: |
| 2. |
No. of temporary staff with their designations: |
| 3. |
Names of the investigations carried out in the Department: |
| 4. |
Name and number of equipments available: |
| (F4) |
BLOOD BANK FACILITIES (In-house or access): Yes No |
| (F5) |
Transplant coordinators |
Yes |
No |
| |
Number Posted: |
| |
Number Trained |
| The abovesaid information is true to the best of my knowledge and I have no objection to any scrutiny of our facility by authorised personnel. I hereby give an undertaking that we shall make the facilities of the hospital including the retrieval team of the hospital available for retrieval of the organ/tissue as and when needed. |
| Sd/- Head of the Institution |
Form 14
Application for Registration of Tissue Banks other than Eye Banks
(TO BE FILLED BY HEAD OF THE INSTITUTION)
[See Rule 24(1)]
To
The Appropriate Authority for organ transplantation ..
(State or Union Territory)
We hereby apply to be registered as Tissue bank, Name:
Name(s) of tissue(s)(Bone, heart valves, skin, cornea etc.) for which Registration is required
The required data about the facilities available in the institution are as follows
| A. |
General Information: |
| 1. |
Name |
| 2. |
Address |
| 3. |
Government/Private/NGO |
| 4. |
Teaching/Non-teaching |
| 5. |
Approached by: |
| |
Rail: |
Yes |
No |
| |
Road: |
Yes |
No |
| |
Air: |
Yes |
No |
| 5. |
Information Education and Communication (IEC) for Tissue Donation |
| 6. |
Type of tissue bank: Auto Logons/Allograph/Both |
| B. |
DONOR SCREENING |
| |
REMOVAL OF TISSUE AND STORAGE: |
| |
1. |
Availability of adequate trained and qualified |
Yes/No |
| |
|
Personnel for removal Tissue |
|
| |
|
(annex detail) |
|
| |
2. |
Names, qualification and address of the doctors/technician who will be doing removal of tissue. |
Yes/No |
| |
|
(annex details) |
|
| |
3. |
Facilities for removal of Tissues |
Yes/No |
| |
4. |
Whether register of recipient waiting list available. |
Yes/No |
| |
5. |
Telephone arrangement available. |
Yes/No |
| |
|
(Telephone Number ..) |
|
| |
6. |
Availability of ambulance/vehicle or funds to Pay taxi for collecting tissue from outside: |
Yes/No |
| |
7. |
Sets of instruments for removal of tissue |
Yes/No |
| |
8. |
Facilities for processing of tissue |
Yes/No |
| |
9. |
Refrigerator for preservation of tissue |
Yes/No |
| |
10. |
Special containers for preservation of tissue during transit |
Yes/No |
| |
11. |
Suitable preservation media |
Yes/No |
| |
12. |
Any other specific requirement as per tissue |
Yes/No |
| C. |
PRESERVATIONS OF TISSUE |
| |
Arrangement of preservation of Tissue |
Yes/No |
| D. |
RECORDS |
| |
1. |
Arrangement for maintaining the records |
Yes/No |
| |
2. |
Arrangement for registration of cases, donors and follow up of cases |
Yes/No |
| E. |
EQUIPMENT: |
| |
Instruments specific for the tissue |
Yes/No |
| F. |
LABORATORY FACILITIES (If the information is exhaustive please annex it) |
|
| |
a. |
Names of the investigations carried out in the department. |
|
| |
b. |
Facility for testing for: |
|
| |
|
i. Human Immunodeficiency Virus Type I and II |
Yes/No |
| |
|
ii. Hepatitis B Virus HBc and HBs |
|
| |
|
iii. Hepatitis C Virus HCV |
|
| |
|
iv. Syphilis VDRL |
|
| |
c. |
If no where do you avail it? Please mention name and address of institute. |
|
| |
d. |
Facility for culture and sensitivity of tissue |
Yes/No |
| |
1. |
No. of permanent staff member with their designation |
|
| |
2. |
No. of temporary staff with their designation |
|
| |
3. |
No. of trained persons |
|
ANY OTHER INFORMATION
The abovesaid information is true to the best of my knowledge and I have no objection to any scrutiny of our facility by authorised personnel. A Bank Daft/cheque of Rs 10,000 (for new registration) and Rs 5000 (for renewal) in favour of .is enclosed.
Sd/
Head of the Institution
Form 15
Application for Registration of Eye Bank, Corneal Transplantation Centre, Eye Retrieval Centre under Transplantation of Human Organs Act
[See Rule 24(1)]
| I. EYE BANKING: |
|
| A. |
EYE BANK and institution affiliated Ophthalmic/General Hospital |
|
| |
1. Name |
|
| |
2. Address |
|
| |
3. Government/Private/Voluntary |
|
| |
4. Teaching/Non-teaching |
|
| |
5. IEC for Eye Donation |
|
| B. |
REMOVAL OF EYE BALLS AND STORAGE: |
|
| |
1. |
Availability of adequate trained and qualified personnel for removal of whole globe or corneal |
Yes/No |
| |
|
(annex detail) |
|
| |
2. |
Names, qualification and address of the designated staff who will be doing removal of whole globe/cornea retrieval. |
Yes/No |
| |
|
(annex details) |
|
| |
3. |
Availability of following as per requirement: |
Yes/No |
| |
|
a. |
Whether register maintained for tissue request received from surgeon of corneal transplant centre. |
|
| |
|
b. |
Telephone arrangement available. |
Yes/No |
| |
|
|
(Dedicated Telephone Number ..) |
|
| |
|
c. |
Transport facility for collecting Eyeballs from outside: |
Yes/No |
| |
|
d. |
Sets of instruments for removal of whole globe/cornea as per requirement |
Yes/No |
| |
|
e. |
Special bottles with stands for preservation of Eye balls/cornea during transit |
Yes/No |
| |
|
f. |
Suitable preservation media |
Yes/No |
| |
|
g. |
Biomedical Waste Management |
Yes/No |
| |
|
h. |
Uninterrupted Power supply |
Yes/No |
| C. |
Manpower |
|
| |
1. |
In-charge/Director (Ophthalmologist) 1 |
|
| |
2. |
Eye Bank Technician 2 |
|
| |
3. |
Eye Donation Counselors (EDC) 2 per attached HCRP (Hospital Cornea Retrieval Cornea Programme) Hospital, who will be posted at Eye Bank. |
|
| |
4. |
Multi Task Staff (MTS) 2 |
|
| D. |
Space requirement for Eye Banks (400 sq ft minimum) |
Yes/No |
| E. |
RECORDS |
|
| |
1. |
Arrangement for maintaining the records |
Yes/No |
| |
2. |
Arrangement for registration of pledges,/donors and maintenance of utilization report |
Yes/No |
| |
3. |
Computer with internet facility and Printer |
Yes/No |
| F. |
EQUIPMENT: |
|
| |
1. |
Slit Lamp Biomicroscope 1 |
Yes/No |
| |
2. |
Specular Microscope for Eye Bank 1 |
|
| |
3. |
Laminar flow(Class II) 1 |
|
| |
4. |
Sterilization facility (In-house or outsourced) |
|
| |
5. |
Refrigerator with temperature monitoring for preservation of eye balls/Cornea 1 |
|
| G. |
LABORATORY FACILITIES |
|
| |
1. |
Facility for HIV, Hepatitis B and C testing. |
Yes/No |
| |
2. |
If no where do you avail it? Please mention Name and address of institute. |
|
| |
3. |
Facility for culture and sensitivity of Corneoscleral ring. |
Yes/No |
| H. |
RENEWAL OF REGISTRATION: |
|
| |
Period of renewal 5 years after last registration. |
|
| |
Minimum of 500 corneas to be collected in 5 years. |
|
| |
Maintenance of eye bank standards (as per Guidelines) |
|
| II. |
EYE RETRIEVAL CENTRE (ERC): |
|
| A. |
RETRIEVAL CENTRE A Centre affiliated to an Eye Bank |
|
| |
1. |
Name |
|
| |
2. |
Address |
|
| |
3. |
Government/Private/Voluntary |
|
| |
4. |
Teaching/Non-teaching |
|
| |
5. |
Information, Education and Communication Activities for Eye Donation |
|
| |
6. |
Name of Eye Bank to which ERC is affiliated. |
|
| B. |
REMOVAL OF EYE BALLS AND STORAGE: |
|
| |
1. |
Manpower : Adequate trained and qualified personnel for removal of eye balls/cornea |
|
| |
|
(annex detail): |
|
| |
|
a. |
In-charge/Director) 1 |
|
| |
|
b. |
Technician 1 |
|
| |
|
c. |
MTS (Multi task Staff) 1 |
|
| |
2. |
Transport facility (or outsource) with storage medium |
|
| C. |
Names, qualification and address of the personnel who will be doing enucleation/removal of cornea. |
|
| |
(annex details) |
|
| D. |
AVAILABILITY OF FOLLOWING: |
|
| |
1. |
Telephone. |
|
| |
|
(Number .) |
|
| |
2. |
Ambulance/vehicle or funds to pay taxi for collecting eyeballs from outside: |
|
| |
3. |
Sets of instruments for removal of Eye Balls/cornea |
|
| |
4. |
Special bottles with stands for preservation of |
|
| |
5. |
Eye balls/cornea during transit: |
|
| |
6. |
Suitable preservation media |
|
| |
7. |
Waste Disposal (Biomedical Waste Management) |
|
| |
8. |
Space requirement: Designated area |
|
| E. |
RECORDS |
|
| |
1. |
Arrangement for maintaining the records |
|
| F. |
EQUIPMENT: |
|
| |
1. |
Sterilization facility |
|
| |
2. |
Refrigerator temperature control 24 hrs for preservation of Eye balls/Cornea. (power backup) 1 |
|
| |
3. |
The retrieval centre is affiliated with an Eye bank and Eye Bank is only authorised to distribute corneas. |
|
| III. CORNEAL TRANSPLANTATION CENTRE |
| A. |
1. |
Name of the Transplant Centre/hospital: |
|
| |
2. |
Address: |
|
| |
3. |
Government/Private/Voluntary: |
|
| |
4. |
Teaching/Non-teaching: |
|
| |
5. |
IEC for Eye Donation: Yes/No |
|
| |
6. |
Name of the registered Eye Bank for procuring tissue: |
|
| B. |
Staff details: |
|
| |
1. |
No. of permanent staff member with their designation. |
|
| |
|
(Note: Eye Surgeon's Experience : 3 month post MD/MS/DNB/DO) |
|
| |
2. |
No. of temporary staff with their designation |
|
| |
3. |
Trained persons for Keratoplasty and Corneal Transplantation with their names and qualifications: 2 (one Corneal Transplant surgeon should be on the pay roll of the Institute) |
|
| C. |
Equipment: Slit lamp, Clinical Specular, Keratoplasty or intraocular instruments |
|
| D. |
OT facilities |
|
| E. |
Safe Storage facility |
|
| F. |
Records Registration and follow up |
|
| G. |
Any other information |
|
The abovesaid information is true to the best of my knowledge and I have no objection to any scrutiny of our facility by authorised personnel. A Bank draft/cheque of Rs 10,000 for new registration and Rs 5000 for renewal of registration drawn in favour of is enclosed.
Head of the Institute
(Name and designation)
Form 16
Certificate of Registration for performing Organ/Tissue Transplantation/Retrieval and/or Tissue Banking
[See Rule 24(2)]
This is to certify that .. Hospital/Tissue Bank located at . has been inspected and certificate of registration is granted for performing the organ/tissue retrieval/transplantation/banking of the following organ(s)/tissue(s)(mention the names) under the Transplantation of Human Organs Act, 1994 (42 of 1994)
1 ..
2 ..
3 ..
4 ..
This certificate of registration is valid for a period of five years from the date of issue.
This permission is being given with the current facilities and staff shown in the present application form. Any reduction in the staff and/or facility must be brought to the notice of the undersigned.
| Place . |
Signature of Appropriate Authority . |
| Date .. |
Seal: . |
Form 17
Certificate of Renewal of Registration
(TO BE GIVEN BY THE APPROPRIATED AUTHORITY ON THE LETTER HEAD)
[See Rule 25(2)]
This is with reference to the application dated from . (Name of the hospital/tissue bank) for renewal of certificate of registration for performing organ(s)/tissue(s) retrieval/transplantation/banking under the Transplantation of Human Organs Act, 1994 (42 of 1994).
After having considered the facilities and standards of the abovesaid hospital/tissue bank, the Appropriate Authority hereby renews the certificate of registration of the said hospital/tissue bank for a period of five years.
This renewal is being given with the current facilities and staff shown in the present application form. Any reduction in the staff and/or facility must be brought to the notice of the undersigned.
| Place .. |
Signature of Appropriate Authority |
| Date . |
Seal .. |
Form 18
Certificate by the Authorisation Committee of Hospital (If Hospital Authorisation committee is not available then the Authorisation Committee of the district/State) where the transplantation has to take place
(TO BE ISSUED ON THE LETTER HEAD)
[See Rules 16 and 23]
This is to certify that as per application in Form 10 for transplantation of (Name of Organ/tissue) from living donor, other than near relative/swap donation cases/all foreigner under the Transplantation of Human Organs Act, 1994 (42 of 1994) submitted on by the donor and recipient, whose details and photographs are given below, along with their identifications and verification documents, the case was considered after the personal interview of donor and recipient (if medically fit to be interviewed) and their relatives as applicable by the Authorisation Committee in the meeting held on .dated ..
| Details of Recipient |
Details of Donor |
| Name .. |
Name .. |
| Age .. |
Age .. |
| Sex |
Sex |
| Father/Husband Name |
Father/Husband Name |
| . |
. |
| Address: |
Address: |
| . |
. |
| . |
. |
| Hospital Reg. No |
Hospital Reg. No .. |
| Relation of donor with Recipient |
| |
|
| Recipient |
Donor |
(Photo of recipient and donor must be signed and stamped across the photo after affixing)
Permission is granted, as to the best of knowledge of the members of the committee, donation is out of love and affection and there is no financial transaction between recipient and donor and there is no pressure on/coercion of the donor.
Permission is withheld pending submission of the following documents
Permission is not granted for the following reasons
| (Member) |
(Member) |
(Member) |
(Member) |
| Name and Designation |
Name and Designation |
Name and Designation |
Name and Designation |
| (Member) |
(Member) |
(Sign of Chairman with stamp) |
|
| Health Secretary |
DHS or Nominee |
Name and Designation |
|
| Or Nominee |
Name and Designation |
|
| Date and place |
| * In case of SWAP transplants, details are to be annexed |
Form 19
Certificate by competent authority [as defined at Rule 2(c)] for Indian near relative, other than spouse, cases (In case of spousal donor, Form 6 will be applicable)
[See Rule 5(3)(c)]
(FORMAT FOR THE DECISION OF COMPETENT AUTHORITY)
This is to certify that as per application in Form 11 for transplantation of .(Name of Organ or Tissue) from living donor who is a near relative of the recipient under the Transplantation of Human Organs Act, 1994 (42 of 1994), submitted on .. by the donor and recipient, whose details and photographs are given below, along with their identifications and verifications documents, the case was considered after the personal interview of donor and recipient (if medically fit to be interviewed) by the competent authority in the meeting held on .
| Details of Recipient |
Details of Donor |
| Name |
Name |
| Age |
Age |
| Sex . |
Sex . |
| Father or Husband Name |
Father or Husband Name |
| . |
. |
| Address: |
Address: |
| .. |
.. |
| .. |
.. |
| . |
.. |
| Hospital Reg. No. |
Hospital Reg. No. .. |
| Relation of donor with Recipient |
| |
|
| Recipient |
Donor |
(Photo of recipient and donor must be signed and stamped across the photo after affixing)
Permission is granted, as to the best of knowledge of the members of the committee, donation is out of their being near relative and there is no financial transaction between recipient and donor and there is no pressure on/coercion of the donor.
Permission is withheld pending submission of following documents .
Permission is not granted for the following reasons
(Signature and stamp of competent authority)
Date and place .
Form 20
Verification certificate in respect of domicile status of recipient or donor
[TO BE ISSUED BY TEHSILDAR OR ANY OTHER AUTHORISED OFFICER FOR THE PURPOSE (REQUIRED ONLY FOR THE DONOR OTHER THAN NEAR RELATIVE OR RECIPIENT IF THEY DO NOT BELONG TO THE STATE WHERE TRANSPLANT HOSPITAL IDENTIFIED FOR OPERATION IS LOCATED)]
[See Rule 14]
Part I (To be filled by applicant donor or recipient separately in triplicate)
In reference to application for verification of domicile status for donation of (Name of organ/Tissue) from living donor (other than near relative) or recipient under Transplantation of Human Organ Act, 1994 (42 of 1994), submitted on (date) . by the applicant donor or recipient, with following details and photograph, along with his or her identification and domicile status for verification
| Details of Applicant Recipient or Donor |
| Name .. Age .. Sex Father or Husband Name .. . Address: . . . Hospital Reg. No. . . |
|
| (Recent Photo of Applicant must be signed by him or her across the photo after affixing it) |
| The detail of my donor or recipient are as under and I have enclosed his or her self-signed recent photograph: |
| Name .. |
| Age |
| Sex . |
| Father or Husband Name . |
| .. |
| Address: |
| .. |
| .. |
| Hospital Reg. No. .. |
| Signature of Applicant |
| Enclosure: Self signed copy of the donor or recipient for the applicant (to be enclosed) |
| Part II (To be filled by the certificate issuing authority): |
| The above request has been examined and it is certified that the domicile status of the applicant donor or recipient mentioned as above has been verified as under: |
| Name Son or Daughter or Wife of resident of village or ward Tehsil or Taluka .. District .. State or UT and found correct or incorrect |
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| Date Place .. |
Authorised Signatory |
| Reference No |
Name and Designation |
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Office Stamp |
2. The authorised signatory will hand over this verification certificate to the applicant or his or her representative for submission to the Chairperson of the Authorisation Committee of the hospital or district or state (as the case may be), where transplantation has to take place.
3. The authorised signatory shall keep one copy of the above verification certificate for his records and send a copy to the Secretary, Health and Family Welfare of the State Government (Attention Appropriate authority for organ transplant) for information.
4. In case of any suspicion of organ trading, the authorised signatory mentioned above or Appropriate Authority of the state may inform police for making enquiry and taking necessary action as per the Transplantation of Human Organs Act, 1994 (42 of 1994).
Form 21
Certificate of relationship between donor and recipient in case of foreigners
(TO BE ISSUED BY THE EMBASSY CONCERNED)
[See Rule 20(a)]
The embassy of (Name of Country) in India, is in receipt of an application received from .. (Name of Organ donor and recipient) on .(Date) recommended by (Name of Government Department of country of origin) for facilitation of donation of . (Name of Organ or Tissue) from living donor (Name of donor) to the recipient (Name of recipient) for therapeutic purposes under the Transplantation of Human Organs Act, 1994 (42 of 1994). The details of donor and recipient and photographs are as given below.
| Details of Recipient |
Details of Donor |
| Name |
Name |
| Age |
Age |
| Sex . |
Sex . |
| Father or Husband Name |
Father or Husband Name |
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| Address: |
Address: |
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| Recipient |
Donor |
| (Photo of recipient and donor must be signed and stamped across the photo after affixing) |
| 1. This is to certify that relationship between donor and Recipient is |
| 2. The authenticity of following enclosed identification and verification documents is certified. |
| a. .. |
| b. .. |
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| No objection certificate is granted, as to the best of my knowledge, the donor is donating out of love and affection or affection and attachment towards the recipient, and there is no financial transaction between recipient and donor and there is no pressure on or coercion of the donor. |
| (Signature of Senior Embassy Official) |
| Date: |
Name: |
| Place: |
Designation . |