Department of Pathology and Anatomical Sciences GIFT OF BODY

Department of Pathology

and Anatomical Sciences

University of Missouri-Columbia

School of Medicine

M263 Medical Science Building

One Hospital Drive DC055.07

Columbia, MO 65212 USA

PHONE (573) 882-1201

FAX (573) 884-4612

pathology-anatomy.missouri.edu

GIFT OF BODY PROGRAM AGREEMENT BY DONOR

PURPOSE

The donation of one’s body historically is an accepted way to contribute meaningfully to essential

advances of medical science. Bodies donated to the University of Missouri-Columbia School of

Medicine are used for educational purposes in the instruction for students training for the medical,

physical therapy, and athletic training professions. Bodies are also used in undergraduate anatomy

courses, largely populated by pre-healthcare professions students, and by physicians and researchers

who are involved in more specific studies to advance educational and basic science research

outcomes in various medical specialties, such as orthopedics, otolaryngology, and plastic surgery.

Any questions concerning the Gift of Body Program (“Program”) should be directed to the Gift of

Body Program Coordinator, Department of Pathology and Anatomical Sciences, University of

Missouri–Columbia School of Medicine, at the above address, or at [email protected] , or at

573.882.2288. General information about the Gift of Body Program may be obtained at:

https://medicine.missouri.edu/departments/pathology-and-anatomical-sciences/gift-of-body .

ENROLLMENT PROCEDURES

The decision to donate your body to the Program is a serious decision, and we strongly encourage

you to discuss your decision with your family. The procedure for enrolling in the Program involves

completing this Agreement, which includes the Authorization For Donation, Personal Information,

Brief Medical History, and Authorization For Disclosure of Health Information, and sending one

original, signed copy to the Program Coordinator at the above address. It is recommended that a

second copy be made for your records, and copies provided to appropriate family members. Wallet

cards will then be issued to facilitate communication with Program representatives upon your death,

and to communicate this information to family and caretakers.

Once you enroll in the Program, the Agreement remains on file in the office of the Department of

Pathology and Anatomical Sciences permanently. If you decide to revoke the Agreement, the

“Notice of Revocation of Authorization for Donation of Body” must be sent to the Program

Coordinator at the above address. Your donation cannot be revoked or overridden by any other

person at any time, even after your death.

PROCEDURES UPON DEATH

Upon death, the Program shall provide notification as to where the body is to be transported, either

to the Medical Sciences Building at the University of Missouri-Columbia or an alternate location.

The cost for transportation and ensuring an appropriate condition of your body until delivered must

be paid from your estate or your next of kin. Other costs typically include the following: 1)

completion and filing of the Missouri Department of Health Certificate of Death by the appropriate

authority (hospital or funeral home); and 2) timely removal of the body (within 12 hours) by a

funeral home and holding it in refrigeration until transportation can be arranged to the Medical

Sciences Building or an alternate location as directed by the Program. Length of refrigeration can

affect acceptance to our Program (see below) so the funeral home must be promptly advised about

the intent for your body to be donated. If your body cannot be accepted into the Program,

representatives of the Program will communicate with your family and/or funeral home regarding

the lack of acceptance.

CONDITIONS FOR ACCEPTANCE

In general, conditions leading to rejection of a body donation include: (1) body not intact (e.g.

autopsy or organ donation with exception of eye donation); (2) presence of a communicable disease

(e.g., tuberculosis, AIDS, or hepatitis) or any bacterial infections; (3) exceeds the maximum weight

of 200 lbs.; (4) body not processed in a timely manner following death; or (5) any recent surgeries

resulting in incisions not completely healed. Occasionally there are times our Program is full; if we

are unable to accept a body, it will be the family’s responsibility to make other arrangements for the

body.

While most bodies donated to the Program are accepted, acceptance cannot be guaranteed. The final

acceptance of a donation is dependent on the body being in a condition suitable for use by our

Program at the time of donation. Please make family members aware of this as it will alleviate

distress if your body is not accepted by the Program. Completion of this Agreement does not

constitute a contract with the University of Missouri, but rather is an indication of your desire to

contribute your body to the MU School of Medicine.

USE OF DONATED BODIES

A donated body will be used by the Program in a manner to be determined exclusively by the

Program, pursuant to the policies and procedures that are in effect at the time of your death or as

they may be revised thereafter.

Donors to the Program understand the following:

• The acceptance and exact use of the donor’s body will be at the discretion of the Program.

Examples of how the body may be used for education or research include, but are not limited

to: medical education and training; advanced clinical training skills; forensic sciences (e.g.,

pathology, engineering, anthropology).

• For the purposes of education or research, the Program reserves the right to permanently

preserve and retain certain tissues and organs of the donor, and/or to create photographic,

video, or media images of parts of donors in ways that respect the donor’s dignity.

• At times, other accredited institutions have need of body donors. In such cases, the donor

body may be transferred to another, approved institution at the discretion of the Program.

Typically after 2-3 years, the remains of the donor’s body, except for any remains retained by

University for educational and research purposes, will be cremated and either interred or returned as

stated in the “Authorization for Donation of Body.” If the person designated in the Authorization to

be contacted for the return of the remains fails to claim the remains within 2 years of cremation

after being notified at the address listed on the Authorization or any updated address, the remains

will be interred at the Memorial Park Cemetery. The cost of interment in Memorial Park Cemetery

is born by the University. The gravesite at Memorial Park represents the commingled remains of

many individuals. Once interred at Memorial Park Cemetery, remains cannot be retrieved. The

location of graves is indicated by a large memorial stone. Individual graves are marked with

headstones indicating the year of interment. Names of all individuals interred are maintained on a

master list, one copy of which is held at the offices of Memorial Park Cemetery.

GIFT OF BODY COMMEMORATION CEREMONY

Donors may be commemorated in a ceremony organized by medical students, faculty, and staff of

the University of Missouri-Columbia. Typically, speakers include faculty and physicians, there are

videos of student expressions of gratitude for the gifts of bodies, and musical performances. It is a

time to pause for reflection of the gifts of bodies for the advancement of medical science at the

University of Missouri-Columbia. Information about the Gift of Body Commemoration Ceremony

shall be provided to the individual designated to receive the information about the interment.

PRIVACY AND SECURITY OF INFORMATION

Any information that is obtained about the donor is confidential, and its privacy and security are

protected from illegal uses and disclosures in accordance with Federal and Missouri laws.

Disclosures will only be made as permitted by law and authorized by the donor or legal

representative.

AUTHORIZATION FOR DONATION OF BODY

Name (Please Print) ________________________________________________

Street Address: ____________________________________________________

City, State, Zip Code: _______________________________________________

I hereby donate my body, following my death, to the Department of Pathology and Anatomical

Sciences, University of Medicine–Columbia School of Medicine. I have read and understand

all of the information contained in this Agreement.

The remains of my body shall be cremated and:

(Initial applicable statement)

______ Interred at the Memorial Park Cemetery in Columbia, MO, with information

about the interment to be provided to (name, address, and phone number):

_____________________________________________________________________________

______ Returned to (name, address, and phone number; please consider identifying

several individuals in the event the first named individual cannot be located or has died):

_______________________________________________________________________

________________________________________________________________________

I hereby direct that my body be delivered to the University of Missouri–Columbia to be used

for educational and research purposed as set forth in this Agreement.

Signature of Donor Date

Signature of Witness Print Name Relationship to Donor Date

If the Donor is physically unable to sign this Authorization, another individual may sign this

Authorization which shall be witnessed by two adults, at least one of which shall be a

disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse,

child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are

indicating that the Donor has authorized and directed the making of this anatomical gift.

____________________________________________________________________________

Signature of Individual Signing at the Direction of Donor Date

_________________________________________________________________

Signature of Disinterested Witness Date

____________________________________________________________________________

Signature of Witness Date

NOTICE OF REVOCATION OF AUTHORIZATION

FOR DONATION OF BODY

I, ________________________________, hereby revoke my Authorization for Donation of

Body, effective immediately.

Signature of Donor Date

If the Donor is physically unable to sign this Authorization, another individual may sign this

Authorization which shall be witnessed by two adults, at least one of which shall be a

disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse,

child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are

indicating that the Donor has authorized and directed the revocation of this anatomical gift.

____________________________________________________________________________

Signature of Individual Signing at the Direction of Donor Date

_________________________________________________________________

Signature of Disinterested Witness Date

____________________________________________________________________________

Signature of Witness Date

PERSONAL INFORMATION

Name: _______________________________________________________________________

Birthplace (city and state, or foreign country):

Date of Birth:

Social Security Number:

Ever in Armed Forces (yes or no):

Marital Status (married, never married, widowed, divorced):

Surviving Spouse/Domestic Partner name (if different

from married name, provide full original name):

Usual Occupation (during most of working life; do not list retired):

Kind of Business or Industry:

Residence - Street and Number:

City, Town, or Location:

State and Country:

Zip Code:

Inside City Limits (yes or no):

Years at Present Address:

Of Hispanic Origin (yes or no - if yes, specify, Cuban, Mexican, Puerto Rican, etc):

Race (American Indian, White, Black, etc):

Years of Education - Elementary (secondary 0-12):

College and/or post-college (1-5 or 5+):

Father's Name:

First Middle Last

Mother's Name:

First Middle Last

Signature:

BRIEF MEDICAL HISTORY

Name:

First

Middle

Last

Date this Form was Completed:

Gender:

Sex Assigned at Birth:

Date of Birth:

Congenital (Inborn) Abnormalities:

Abnormalities Acquired Through Injury or Disease:

Major Surgeries and Approximate Dates: ____________________________________________

Communicable Diseases (examples include hepatitis, HIV, AIDS, pertussis, rabies, tetanus,

Methicillin-resistant staphylococcus aureus [MRSA]):

______________________________________________________________________________

Present State of Health: __________________________________________________________

Additional Information Relating to Physical Condition: _________________________________

Signature: ___________________________________

GIFT OF BODY PROGRAM AUTHORIZATION FOR

DISCLOSURE OF HEALTH INFORMATION

Donor’s Name: ____________________________________________________

Date of Birth: ____________________________________________________

Address: ____________________________________________________

Phone Number: ____________________________________________________

This Authorization is for the Gift of Body Program (“Program”) at the University of Missouri-

Columbia School of Medicine, Department of Pathology and Anatomical Sciences

(“University”) to disclose certain information about you if your body is accepted as a gift to the

Gift of Body Program. The permissible disclosures may be made to non-University outreach

groups for educational purposes only.

The following information about you may be disclosed by University: Name; address; age;

occupation; minimal medical information; cause of death.

This Authorization may be revoked by you at any time in writing to University. This

Authorization becomes effective upon signing and will expire five (5) years after your death.

_____________________________________ ______________________

Signature of Donor Date