State Organ and Tissue Transplant Organisation
Goa Medical College

1

FOR ORGAN/TISSUE DONATION FROM IDENTIFIED LIVING NEAR RELATED DONOR
(to be completed by HIM OR HER)

2

FOR ORGAN/TISSUE DONATION BY LIVING SPOUSAL DONOR
(to be completed by HIM OR HER)

3

FOR ORGAN/TISSUE DONATION BY OTHER THAN NEAR RELATIVE LIVING DONOR
(to be completed by HIM OR HER)

4

FOR CERTIFICATION OF MEDICAL FITNESS OF LIVING DONOR
(to be given by The Registered Medical Practitioner)

5

FOR CERTIFICATION OF GENETIC RELATIONSHIP OF LIVING DONOR WITH RECIPIENT
(To be filled by The Head of Pathology Laboratory certifying relationship)

6

FOR SPOUSAL LIVING DONOR
(to be filled by concerned by Competent Authority* and Authorization Committee, of the hospital or district or State in case of foreigners)
*Director or Medical Superintendent or In charge of the Hospital or the Internal committee of the Hospital formed for the purpose. As defined under the rules of Transplantation of Human Organ Act,1994(42 of 1994).

7

FOR ORGAN TISSUE PLEDGING
(to be filled by INDIVIDUAL of 18 years or above)

8

FOR DECLARATION CUM CONSENT
(to be filled by Near Relative / Lawful Possessor of brain stem dead person)

9

FOR UNCLAIMED BODY IN A HOSPITAL/PRISON
(to be completed by Person in lawful possession of the unclaimed body)

10

FOR CERTIFICATION OF BRAINSTEM DEATH
(to be filled by the Board of medical experts certifying brainstem death)

11

APPLICATION FOR APPROVAL OF TRANSPLANTATION FROM LIVING DONOR
(to be completed by the proposed Recipient & the proposed Living Donor)

12

APPLICATION FOR REGISTRATION OF HOSPITAL TO CARRY OUT ORGAN OR TISSUE TRANSPLANTATION OTHER THAN CORNEA
(to be filled by head of the institution)

13

APPLICATION FOR REGISTRATION OF HOSPITAL TO CARRY OUT ORGAN/TISSUE RETRIEVAL OTHER THAN EYE/CORNEA RETRIEVAL
(to be filled by head of the institution)

14

APPLICATION FOR REGISTRATION OF TISSUE BANKS OTHER THAN EYE BANKS
(to be filled by head of the institution)

15

APPLICATION FOR REGISTRATION OF EYE BANK, CORNEAL TRANSPLANTATION CENTRE, EYE RETRIEVAL CENTRE UNDER THE TRANSPLANTAION OF HUMAN ORGANS ACT.

16

CERTIFICATE OF REGISTRATION FOR PERFORMING ORGAN/TISSUE TRANSPLANTATION/RETRIEVAL AND /OR TISSUE BANKING.

17

CERTIFICATE OF RENEWAL OF REGISTRATION
(to be given by the appropriated authority on the letter head)

18

CERTIFICATE BY THE AUTHORIZATION COMMITTEE OF HOSPITAL (If Hospital authorization committee is not available then the Authorization committee of the district/state) where the transplantation has to take place (to be issued on the letter head).

19

CERTIFICATE BY CONCERNED COMPETENT AUTHORITY (as defined at rule 2(c) for Indian near relative, other than spouse, cases (in case of spouse donor, Form 6 will be applicable).

20

VERIFICATION CERTIFICATE IN RESPECT TO DOMICILE STATUS OF RECIEPIENT OR DONOR
{(To be issued by tehsildar or any other authorized officer for the purpose (required only for the donor-other than near relative or recipient if they do not belong to the state where transplant hospital identified for operation is located)}

21

CERTIFICATE OF RELATIONSHIP BETWEEN DONOR AND RECIPIENT IN CASE OF FOREIGNERS
(To be issued by the Embassy concerned)