Transplant of Human Organs - Forms 8,9,10,11,12,13

FORM - 8
[(See rule 4(3) (a) and (b)]
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 function of the brain stem. The test carried out by us and the findings therein are recorded in the brain stem death Certificates annexed hereto.
Dated.................................... Signature............................................
1. R.M.P Incharge of the Hospital in which brain-stem death has occurred.

2. R.M.P. nominated from the panel of
names approved by the Appropriate Authority
3. Neurologist / Neuro Surgeon nominated
. from the panel of names approved by
Appropriate Authority.
4. R.M.P. treating the aforesaid deceased person
BRAIN STEM DEATH CERTIFICATE

(A) PATIENT DETAILS :
1. Name of the Patient Mr/Ms. ....................................…….......................... S.O./D.O./W.O. Mr. ........................................ .................... .......... Sex................................ Age ....................... 2. Home Address ......................................................................
......................................................................

3. Hospital Number ..................................................................... . . ....................................................................

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 transplant ? .....................................................................
6. In this a police Case ? Yes.............................No............................

(A) PRE-CONDITIONS:

1. Diagnosis : Did the patient suffer from any illness or accident that led to irreversible brain damage? Specify details ..............................................................................................
...........................................................................................................................................
Date and time of accident/onset of illness ............................................................................
Date and onset of no-responsible coma …............................................................................
2. Finding of Board of Medical Experts : (i) The following reversible causes of coma have been excluded:

Intoxication (Alcohol)
Depressant Drugs
Relaxants (Neuromuscular blocking agents)

First Medical Examination Second Medical Examination

1st 2nd 1st 2nd
Primary hypothermia
Hypovolaemic shock
Metabolic or endocrine disorders
Tests for absent of brain stem functions
2) Coma
3) Cessation of spontaneous breathing.
4) Pupillary Size
5) Pupillary light reflexes
6) Doll's head eyes movement
7) Corneal reflexes (Both Sizes)
8) Motor response in any cranial nerve distribution, any responses to simulation of face limb of 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 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/Mrs................................................................. is declared brain-stem dead.
1. Medical Administrator Incharge of the hospital 2. Authorised Specialist
3. Neurologist/ Neuro Surgeon 4. Medical officer treating patient.
NB. I. The minimum time interval between the first testing and second testing will be six hours.
II. No.2 and No.3 will bo co-opted by the administrator incharge of the hospital from the panel of experts approved by the appropriate authority.

FORM 9
(See rule 4(3) (b))

I, Mr/Mrs....................................son of / wife of.......................resident of...........................
hereby authorise removal of the organ/organs namely..................................for therapeutic
purposes from the dead body of my son/daughter .
Mr/Ms...............................................................aged.........................whose brain stem
death has been duly certified in accordance with the law
Signature..............................

Name....................................

Place.....................................

Date........................................

FORM -10

APLICATION FOR APPROVAL FOR TRANSPLANTATION LIVE DONOR OTHER THAN NEAR RELATIVE
Whereas I ....................................................S/O, D/O, W/O, L/O.............................aged
residing...................................................................have been informed by my doctor that I am suffering from.......................and may be benefitted by transplantation ......................... into my body.
and whereas I ......................................................…………………………….. S.O. D.O. W.O......................................... aged .................. residing at..........................................by reason of affection and attachment because :
..............................................................................................................................................
..............................................................................................................................................
(reason to be filled in) would like to donate my....................................to............................we.................................

(donor)
and............................................hereby apply to authorisation committee for permission (Recipient) 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.
............................................................................................................................................
............................................................................................................................................

Signature and address of prospective Signature and address of prospective

donor recipien

FORM 11
APPLICATION FOR REGISTRATION OF HOSPITAL TO CARRY OUT ORGAN TRANSPLANTATION

To

The Appropriate Authority for organ transplantation ..............................
(State of Union Territory) We hereby apply to be recognised as an institution to carry out organs transplantation. The required data about the facilities available in the hospital are as follows:-
(A) HOSPITAL

1. Name ....................................................................................
2. Location ....................................................................................
3. Govt./pvt. ....................................................................................
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 turn-over/year : ....................................................................................

(B) SURGICAL TEAM :

1. No.of beds ....................................................................................
2. No. of permanent staff members with their designations ........................... ..................
3. No. of temporary staff with their designations ..................................... ...................... ........ 4. No. of operations done per year ....................................................................................
5. Trained persons available for ................................................................................... transplantation (Please specify organ for transplantation)

(C) MEDICAL TEAM:
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. No. of potential transplant candidates admitted per year .............................. ...................

(D) ANAESTHESIOLOGY

1. No. of permanent staff members with their designation ..... ......... .... .................... ...
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 theatres ...........................................................

(E) I.C.U. / H.D.U. FACILITIES :
1. ICU/HDU facilities : Present.....................Not Present..............
2. No. of I.C.U beds .................................................................
3.Trained
Nurses .................................................................. Technicians ..................................................................
4. Name and number of equipments in ICU
(F) OTHER SUPPORTIVE FACILITIES
Data about facilities available in hospital.

(G) 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 Dept

4. Name and number of equipments available
   

(H) IMAGING SERVICES
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 Dept
4. Name and number of equipments available

(I) HAEMATOLOGY SERVICES
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 Dept
4. Name and number of equipments available

(J) BLOOD BANK FACILITIES: Yes........................... No....................
(K) DIALYSIS FACILITIES Yes........................... No.................…
(L) OTHER PERSONNEL

1. Nephorlogist Yes/No

2. Neurologist Yes/No

3. Neuro-Surgeon 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
    

The above said 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. 1,000/- is being enclosed.
sd/-

HEAD OF THE INSTITUTION

FORM-12 CERTIFICATE OF REGISTRATION This is to certify that.....................................Hospital located at..............................…... has been inspected by the Appropriate Authority and certificate of registration is granted for performing the organ transplantation of the following organs 1. ................................................... 2. .................................................... 3. ................................................... 4. .................................................... This certificate of registration is valid for a period of five years from the date of issue. Signature...................................................... Signature.................................... FORM-13 (See sub-rule 8(2)) OFFICE OF THE APPROPRIATE AUTHORITY This is with reference to the application, dated..................................from.................... (Name of the hospital) for renewal of certificate of registration for performing organ transplantation under the Act. After having considered the facilities and standards of the above said hospital the Appropriate Authority hereby renews the certificate of registration of the said hospital for the purpose of performing organ transplantation for a period of five years. Appropriate Authority.................. Place............................................. Date..............................................