Feedback | Enquiry | Sitemap | Bookmark and Share
MOHAN Foundation Register Now | Sign In
Custom Search
Follow us on Twitter
Become a Fan of MOHAN Foundation
Chennai -Activities - Donor Families honored on World Kidney Day    |    Training - Join our Transplant Coordinators Training. Book your place now . Send us a mail    |    Andhra Pradesh - 36 candidates join training Course for coordinators at Hyderabad    |    Chennai -Activities - Awareness Program on organ donation at TIDC on Feb 24 2010    |    Training - 14 candidates complete one month Transplant Coordinators Training programme at Chennai    |    Survey - Take a Survey On Organ Donation -click here..
 MOHAN Foundation » THO Rules New Form » Form - 1(b)

TRANSPLANTATION OF HUMAN ORGANS
The Transplantation of Human Organs Act, 1994
The Transplantation of Human Organs Rules - 1995 (GSR 571(E), dt.31-7-2008)
The Transplantation of Human Organs Rules - New Forms - 1995 (GSR 571(E), dt.31-7-2008)
The Transplant of Human Organs Act - Review Committee

THE TRANSPLANTATION OF HUMAN ORGANS RULES, 1995

FORM 1(B)
[To be completed by the prospective spousal donor]
[Refer rule 3]
My full name is .............................................And this is my photograph
Photograph of the Donor
(Attested by Notary Public)
To be affixed and attested by Notary Public after it is affixed.
My permanent home address is
......................................................................................................
.................................................................Tel:.................................
My present home address is
......................................................................................................
..................................................................Tel:................................
Date of birth............................(day/month/year)

I authorize to remove for therapeutic purposes / consent to donate my...............(state which organ) to my husband/wife ........................ Whose full name is ....................... Who was born on..............................(day / month / year) and whose particulars are as follows:
Photograph of the Donor
(Attested by Notary Public)
To be affixed and attested by Notary Public after it is affixed.

• Ration/consumer Card number and Date of issue & 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 ...........................................
and/or
• PAN..............................................................
and/or
• Other proof of identity and address ...........................................

I submit the following as evidence of being married to the recipient:-
  1. A Certified copy of a marriage certificate
    2. or
  2. An affidavit of a “near relative” confirming the status of marriage to be sworn before Class-I Magistrate / Notary Public.
  3. Family photographs.
  4. Letter from member of Gram Panchayat / Tehsildar / Block Development Officer / MLA / MP certifying factum and status of marriage.
    5. or
  5. Other credible evidence
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 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 ........................... (organ) 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 my knowledge and nothing material has been concealed by me.
..........................................
...............
Signature of the prospective donor
Date

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. 
•  √Wherever applicable.

Page 1 of 1

Go Back
Print E-Mail

Last Updated - - Designed & Content Managed by Medindia Health Network Pvt Ltd. Hosted & Technical Support by FrontPoint Systems

Best viewed with resolution 1024 * 768 px.

Copyright © 2010 MOHAN Foundation. All Rights Reserved.

Disclaimer : The contents of the site are information purpose only. Always keep the advice of Your physician or other qualified health professional regarding any questions you may have about a medical condition.

Home | About us | Our Services | Photo Gallery | Videos | Contact Us