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.....................Email:................................. * 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..................................................Email:........................................................ (Signature of Witness 2) 2.Shri/Smt./Km....................................................................S/o,D/o,W/o................................................................................ aged......................... resident of......................................... Telephone No........................................ Email:................................