Hong Kong Regulations

HUMAN ORGAN TRANSPLANT REGULATION - SCHEDULE SCHEDULE

(Past version on 01/04/1998).

[section 3]

FORM 1 [section 3(1) & (5)] (L.N. 615 of 1997)

HUMAN ORGAN TRANSPLANT ORDINANCE (CHAPTER 465) HUMAN ORGAN TRANSPLANT
REGULATION

INFORMATION ON ORGAN REMOVAL FOR DONATION

Serial Number:
(for internal use) I. Particulars of the Donor

Full name:
...........................................................................
..........................................
(in BLOCK letters, Surname first)
HKIC/Passport* No.:
......................................................................
Age: ......................
Sex: M/F*
Marital status (if donor is living): Single/Married*
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   (a)  □ The donor was LIVING at the time of the removal of the organ(s)-

   (i)  □ The donor and the recipient are genetically related. They are
        ..................................
(please state the genetic relationship) and a copy of proof is enclosed. I am
satisfied that the requirements in section 5(4)(b)-(e)/section 5(4)(b),

   (c)  (insofar as it relates to the donor), (d) and (e) and (6A)* of the
        Human Organ Transplant Ordinance have been complied with.

   (ii) □ The donor and the recipient are a married couple. Their marriage
        has subsisted for
not less than 3 years and a copy of proof is enclosed. I am satisfied that the
requirements in section 5(4)(b)-(e)/section 5(4)(b), (c) (insofar as it
relates to the donor), (d) and (e) and (6A)* of the Human Organ 
Transplant Ordinance have been complied with.

   (iii) □ The donor and the recipient are neither genetically related nor a
        married couple
whose marriage has subsisted for not less than three years. Approval has been
given by the Human Organ Transplant Board for the removal and transplant
through File Reference ......................................... dated
.............................................. .
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   (b)  □ The donor was DEAD at the time of the removal of the organ(s)-
Time and date of death: ........................... am/pm; ............
/............. / ............
	Day Month           Year

Cause of death (please state "pending coroner's inquest" for such cases and
supply the cause of death to the Human Organ Transplant Board as soon as it is
available):
...........................................................................
.....................................................
II. □ Organ(s) removed
Description of the organ(s) removed:
...........................................................................
...
Date of the removal: ............ / ............ / ............
	Day Month           Year

Name of the hospital/clinic/institution where the removal of the organ(s) took
place:
(Also state the address if the removal of the organ(s) took place in
clinic/institution)
...........................................................................
..........................................................
...........................................................................
..........................................................
III. □ Organ(s) not removed within 30 days after approval given by Human
Organ Transplant
Board
Description of organ
...........................................................................
.......................
Approval was given by the Human Organ Transplant Board through File Reference
........... dated ............... but no removal subsequently took place
because (please state reasons):
...........................................................................
.....................................................
IV. □ Organ(s) removed but not transplanted
The organ(s) was/were removed but no transplant subsequently took place within
30 days after the removal because :
(please tick as appropriate)

   (a)  □ The organ(s), after removal, was/were considered to be unusable-
Description of unusable organ(s):
.....................................................................
(Complete ONLY if more than one organ has been removed as stated in Part II)
Reason(s) why organ(s) was/were unusable:
...................................................
Manner of disposal:
...........................................................................
...........
Date of disposal: ............. /.............. /..............
	Day    Month           Year


   (b)  □ # The organ(s) removed is/are being kept in:

   (i)  □ The hospital/clinic/institution stated in Part II above

   (ii) □ Other institution (please specify name and address):
...........................................................................
.....................................
V. Extension of Deadline
□ A request for extending the deadline for submission of the Form has been
made and approval has been given by the Human Organ Transplant Board. (Please
state the File Reference and date of the approval for the extension):
............................................................
VI. Submitted under section 6 of the Human Organ Transplant Ordinance by-
Dr. ........................................................ HKIC/Passport*
No.: .............................
(Full name in BLOCK letters, Surname first)
Telephone number: .............................................. Fax number:
.....................................
Address/Hospital name:
...........................................................................
......................
Date: ...................................................................
Signature: ........................................

* Please delete whichever is inappropriate. □ Please tick if applicable and
fill in the information as required. # In future, when the stored organ(s)
is/are used for transplant, Form 2 must be submitted by the person who
transplants it/them into the recipient. If the organ(s) is/are subsequently
found unsuitable for transplant, the person who makes the decision to dispose
of the organ(s) must submit Form 3 to the Board within 30 days of the disposal
of the organ(s). Notes: 1. This form must be completed by the medical
practitioner who removed the organ(s) or the medical practitioner authorized
by the organ bank in the case where the technician appointed by the bank
removed the organ(s) from the dead donor or, where no organ was removed but
prior approval was given by the Board, it must be completed by the person who
caused the matter to be referred to the Board for its approval or, where that
person is no longer involved, by the person who made the decision not to
remove the organ. Where more than one medical practitioner was involved in
removing the organ, any of them can submit the information in Form 1. However,
the medical practitioner who was in charge of the operation or the medical
practitioner who is in charge of the organ bank is responsible for ensuring
that Form 1 is submitted. 2. One form should be used for each donor. 3. Unless
the Board has given approval for extension of the submission deadline, this
form must be submitted within 30 days of the removal of the organ or the
Board's approval if no removal subsequently took place. (L.N. 615 of 1997;
L.N. 66 of 1999)

FORM 2 [section 3(1)]

HUMAN ORGAN TRANSPLANT ORDINANCE (CHAPTER 465) HUMAN ORGAN TRANSPLANT
REGULATION

INFORMATION ON ORGAN TRANSPLANT

Serial Number:
(for internal use) I. Particulars of the Recipient
Full name:
...........................................................................
..........................................
(in BLOCK letters, Surname first)
HKIC/Passport* No.:
........................................................................
Age: ..................
Sex: M/F*

II. Particulars of the Organ
□ The organ is donated locally-
Full name of the Donor:
...........................................................................
.................
(in BLOCK letters, Surname first)
HKIC/Passport* No.:
.....................................................................
□ The organ is imported-
Please state the date of submission of the certificate accompanying the organ
to the Board under Section 7(1) of the Ordinance: ............. /.............
/............
	Day Month   Year

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Description of the organ transplanted:
........................................................................... ..
Date of the transplant: ............ / ............ / ............
Day Month Year
Name of the hospital/clinic/institution where the transplant of the organ took
place:
(Also state the address if the transplant of the organ took place in
clinic/institution)
...........................................................................
.........................................................

III. Extension of Deadline
□ A request for extending the deadline for submission of the Form has been
made and approval has been given by the Human Organ Transplant Board. (Please
state the File Reference and date of the approval for the extension)
..............................................................
IV. Submitted under section 6 of the Human Organ Transplant Ordinance by-
Dr. ..................................................................
HKIC/Passport* No.: ...........................
(Full name in BLOCK letters, Surname first)
Telephone number: ...................................................... Fax
number: ..............................
Address/Hospital name:
...........................................................................
......................
Date: ............................................................. Signature:
..............................................

* Please delete whichever is inapplicable. □ Please tick if applicable and
fill in the information as required. Notes: 1. This form must be completed by
the medical practitioner who transplanted the organ into the recipient. Where
more than one medical practitioner was involved in transplanting the organ,
any of them can submit the information in Form 2. However, the medical
practitioner who was in charge of the operation is responsible for ensuring
that Form 2 is submitted. 2. One form should be used for each organ
transplanted. 3. Unless the Board has given approval for extension of the
submission deadline, this form must be submitted within 30 days of the
transplant of the organ into the recipient. (L.N. 66 of 1999)

FORM 3 [section 3(1)]

HUMAN ORGAN TRANSPLANT ORDINANCE (CHAPTER 465) HUMAN ORGAN TRANSPLANT
REGULATION

INFORMATION ON FINAL DISPOSAL OF ORGAN REMOVED/IMPORTED

Serial Number:
(for internal use) I. Particulars of the Donor (for organs removed in Hong
Kong)

   (i)  Full name:
        ...........................................................................
        .....................................
(in BLOCK letters, Surname first)

   (ii) HKIC/Passport* No.:
        ...........................................................................
        ....................
For imported organ only

   (i)  Name of donor in full:
        ...........................................................................
        ....................
(in BLOCK letters, Surname first)

   (ii) Name of airline or carrier:
        ...........................................................................
        .............

   (iii) Date of shipment: ............. / ............. / .............
	Day Month     Year

II. Disposal of Organ

   (i)  Description of the organ:
        ...........................................................................
        ..............

   (ii) Reason(s) why the organ was considered unusable:
...........................................................................
....................................................

   (iii) Manner of disposal of the organ:
...........................................................................
.....................................................

   (iv) Date of disposal: ............. / ............. / .............
	Day   Month   Year

III. Submitted under section 6 of the Human Organ Transplant Ordinance by-
Dr./Mr/Ms* ................................................................
HKIC/Passport* No.: .................
(Full name in BLOCK letters, Surname first)
Telephone number: ............................................................
Fax number: ........................
Address/Hospital name:
...........................................................................
......................
...........................................................................
..........................................................
Date: ............................................................ Signature:
...............................................

* Please delete whichever is inappropriate. Notes: 1. This form must be
completed by the person who made the decision to dispose of the organ. 2. One
form should be used for each organ. 3. Unless the Board has given approval for
extension of the submission deadline, this form must be submitted within 30
days of disposal of the organ.