Organ Donation Authorization Questions

This comprehensive list shows the thorough medical and social history that organ donation organizations need to ensure the safety and suitability of donated organs and tissues. The questions cover a range from basic medical history to lifestyle factors, travel history, and potential disease exposures.

Initial Questions

  • Do you have any questions that we can address for you right now?
  • Do we need interpreter services right now?

Organ and Tissue Donation Choices

For each of the following, the family is asked to respond yes or no:

Organs for Transplant:

  • Heart
  • Liver and associated vessels
  • Kidneys
  • Pancreas and spleen
  • Lungs
  • Digestive tract

Tissues:

  • Whole heart for valves (including the pericardium)
  • Eye tissue (cornea, whole eye and other ocular tissue)
  • Skin split thickness
  • Skin full thickness at the front and back of torso, arms and legs
  • Bones, tendons, ligaments, muscles and nerves surrounding soft tissues (arms, shoulders, legs and pelvis)
  • Ribs and costal cartilage
  • Blood vessels in the legs and abdomen
  • Adipose tissue (fatty tissue)

Research and Education Authorization

  • Do you permit the use of organs and tissues authorized above for the purposes of research and education, if not suitable for transplantation?

Tissue Use Agreements

  • Do you agree that these tissues may be used for procedures outside of the United States?
  • Do you agree that these tissues may be used for cosmetic surgery purposes?
  • Do you agree that these tissues may be used by for-profit tissue processors and distributors?

Medical and Social History Questions

General Health Questions:

  • Do you feel you knew your loved one well enough to answer questions regarding their or her medical behavioral history?
  • Where were they born?
  • What was their occupation?
  • Did they have any health problems due to exposure to toxic substances such as pesticides, lead, mercury, gold, asbestos, Agent Orange?
  • Did they have a family physician or a specialist?
  • Did they use a medical facility such as a clinic or an urgent care for anything?

Medications and Symptoms:

  • Did they take any prescription medication recently or on a regular basis?
  • Did they take any non-prescribed medication, such as dietary supplements or vitamins?
  • Did they recently have any symptoms such as a fever, cough or diarrhea?
  • Did they recently have swollen lymph nodes or glands in neck, armpits or groin?
  • Did they have sudden weight loss or a rash?
  • Did they have night sweats?
  • Did they have a severe headache?
  • Did they have a rapid decline in mental ability, seizures, tremors?
  • Did they have difficulty walking?
  • Did they have any allergies?

12-Month History Questions:

  • Did they know anyone who had the smallpox vaccination?
  • In the past 12 months, were they bitten or scratched by any pet, stray farm or wild animal?
  • In the past 12 months, were they told by a healthcare professional that they had or was suspected of having West Nile virus infection?
  • In the past 12 months, did they have any shots or immunizations (flu shot, COVID-19, MMR, yellow fever, hepatitis B or smallpox vaccine)?
  • In the past 12 months, did they get a tattoo, touch-up of an old tattoo, or permanent makeup?
  • In the past 12 months, did they have acupuncture, ear or body piercing?
  • In the past 12 months, did they live with a person who has hepatitis?
  • In the past 12 months, did they come into contact with someone else's blood?
  • In the past 12 months, did they have an accidental needle stick?
  • In the past 12 months, did they have a sexually transmitted infection (syphilis, gonorrhea, chlamydia, genital ulcers, herpes or genital warts)?

Sexual History Questions:

  • In the past five years, were they sexually active even once?
  • Did they have sex in exchange for money or drugs?
  • Did they have sex with another male?
  • Did they have sex with a person who has had sex in exchange for money or drugs?
  • Did they have sex with a person who used a needle to inject drugs that were not prescribed by their own doctor?
  • Did they have sex with a person who had a positive test for or was suspected of having hepatitis B, hepatitis C or HIV?

Drug and Alcohol Use:

  • Did they ever use or take drugs such as steroids, cocaine, heroin, amphetamines or anything not prescribed by their doctor?
  • Did they ever smoke?
  • Did they ever drink alcohol? (If yes: What would they drink? How often? How many drinks at a time? When did they start drinking?)

Medical History Questions:

  • Did they ever have a transplant or medical procedure that involved being exposed to live cells, tissues or organs from an animal?
  • Did they live with or have sex with somebody who had [a transplant/procedure with animal cells]?
  • Was they ever told by a physician that they had a disease of the brain, or a neurological disease (Alzheimer's, Parkinson's, multiple sclerosis or epilepsy)?
  • Was they ever refused as a blood donor or told not to donate?
  • Did they ever have any kind of surgery?
  • Did they ever travel or live outside the United States or Canada?
  • Did they ever receive a blood transfusion or other medical treatment outside the United States?
  • Was they ever a US military member, a civilian military employee or a dependent of either?
  • Did they ever use or take growth hormone?
  • Did they ever have a positive or reactive test for HIV, AIDS virus, hepatitis?
  • Did they ever have liver disease?
  • Did they ever have malaria?
  • Was they ever told by a healthcare professional that they was infected with Ebola virus?
  • Did they ever have cancer?
  • Did they ever have a lung disease such as asthma, COPD or emphysema?
  • Did they ever have tuberculosis or a positive skin or blood test for tuberculosis?
  • Did they ever live with or spend time with a person who had tuberculosis?
  • In the past 12 months, did they live with a person who has tuberculosis?
  • Did they ever have diabetes?
  • Did they ever have kidney disease, kidney stones or frequent kidney infections?
  • Were they ever treated with dialysis?
  • Did they ever have high blood pressure or high cholesterol?
  • Did they ever have a heart attack or heart disease?
  • Did they ever have circulation problems of the legs?
  • Did they ever have an autoimmune disease?
  • Did they ever have any eye problems, procedures or surgeries for their eyes?
  • Did they or any of their relatives have Creutzfeldt-Jakob disease (CJD)?
  • Did they ever live in a homeless shelter?
  • Were they ever in lock up, jail, prison, or any juvenile correctional facility?

Family History:

  • Does their family have a history of diabetes?
  • Does their family have a history of cancer?
  • Is there a family history of coronary artery disease?

COVID-19 Questions:

  • In the last 14 days, were they told by a healthcare professional that they were infected with or suspected to have COVID-19?
  • In the last 14 days, were they in close contact with a person who had confirmed COVID-19?

Additional Questions:

  • In the past nine years, did they receive medication for a bleeding disorder such as hemophilia?
  • In the last five years, did they have sex with a person who had received medication for a bleeding disorder?
  • Are there any other medical conditions you are aware of that we have not yet discussed?
  • Do you now have any concerns that the donation should not proceed?
  • Are there other people, including healthcare professionals, who may provide additional information?

Administrative Questions

  • Would you be interested in displaying your loved one’s name on the funeral home wall?
  • Would you like to receive correspondence from our aftercare program?
  • Do you know anyone in your family or network who is on a transplant waiting list? (Directed donation)