Form 1 Donor Recipient Life Stories Form

Share Your Story

Donor and recipient stories are the most powerful ways to tell others about the importance of signing up as an organ, eye, and tissue donor. Every donor and recipient has a story to tell and this is an opportunity to share yours on organdonor.gov. If you wish to provide your story, complete and submit the form below. You must be 18 or over to submit a story.

Only the first name (or alias) of you or the featured person and approximate age at transplant or donation will appear with your final story (and picture) on organdonor.gov.

Before you begin:

1. Choose the digital photo you plan to submit. Only you (or the featured individual) can be included in the photo, therefore, you may need to crop your photo before submitting.

2. Write the story offline in a text editing software (such as Microsoft Word) and then cut and paste it into the form below. This will help prevent the loss of your story if the website times out before you submit it.

.About You (the Story Submitter):

First Name ____________________ Email Address ________________________

Relationship to the featured person:

• Self (If featured person is living and over the age of 18, he/she must submit his/her own story)

• Parent

• Other, please specify: ________________

About the Featured Person (Items with an asterisk (*) will be shown on the website):

To protect your privacy, you have the option to give the featured person’s first name or to create an alias. Only the name listed in the following field will be displayed with your story, regardless of any other information provided in this form.

*First Name or Alias______ *Role in Story (pick all that apply) Recipient Donor Other _________________ *Age at time of donation or transplantation (Dropdown of age ranges: 0 – 10 11- 20 Etc.)

*Type of organ/tissue donated or received (check all that apply) Heart Lung Liver Kidney Pancreas Intestines Corneas Middle ear Blood vessels Bone Skin Other ________________

The following two items will be collected for verification purposes only and will not be published:

Date of donation/ transplant ________

Affiliated organization (OPO, transplant hospital, eye or tissue bank, etc.) _________________________________________

Story:

Tell us your story. Here are some ideas to get you started.

For recipients: Describe and introduce the recipient (e.g., “I was an avid runner and high school track coach...”). Describe the health problem. What health condition(s) led to the need for transplant? What organ, eyes, or tissues did the recipient need? (e.g.., at the young age of 35, I experienced heart problems...). What was the outcome? (e.g., after being on the waiting list for 5 months, I received a heart transplant...). What is the recipient doing today? (e.g., thanks to the donor’s gift, I saw my daughter turn 4 and continue to teach.) 

For deceased donors: Describe and introduce the donor (e.g., “Judy, a schoolteacher, loved to ride horses and spend time with her children...”). Describe the circumstances related to the donation, such as events leading up to the decision to donate (e.g., after a tragic accident...). Describe the decision to donate (e.g., Judy had registered as a donor making it easier on her family, or Judy’s family discussed their options, and in the end decided to give the gift of life to other individuals). What’s happening now (e.g., Judy’s legacy lives on by...).

For living donors: Describe and introduce the donor (e.g., “Before I became a living donor I was a schoolteacher, rode horses and spent time with my children...”). Describe the circumstances related to the donation, (e.g., events leading up to the decision to donate, my mother was in desperate need of a transplant). Describe the decision to donate (e.g., I learned about living donation and decided to give my mother one of my kidneys). What’s happening now (e.g., I am healthy and continue to teach, ride horses, and spend time with my children. My mother is also healthy and continues to enjoy her grandkids).

Do not include the names of any individuals other than the specific donor or recipient featured in the story. If you wish to mention or acknowledge another person, please use descriptors such as “my/his brother,” “the doctor,” or “the donor,” etc.

Photo:

Upload a photo of the donor or recipient featured in the story. Only the person featured in the story can be shown in the photo. Please crop the photo so no one else is pictured.

Authorization:

I hereby voluntarily and without compensation authorize the use of my image, and my “story” by the Health Resources and Services Administration (HRSA), Division of Transplantation, of the Department of Health and Human Services (HHS).  Accordingly, I grant to the federal government, and those acting on their behalf the right to reproduce, publish, create derivative works (e.g., edit or modify), publicly display or otherwise use my story for federal purposes. I understand that the published version of the story (including my image and other information submitted by me in my story)) will be a public access publication and may be used on other websites or in other publications produced or funded by HRSA, HHS, and those acting on their behalf for federal purposes.

I understand that:

• My story may be edited, and I agree that no product need be submitted to me for any further approval. 

• I may request the removal or revision of my story from HRSA’s website with written notification, and HRSA will make reasonable efforts to comply with my request. 

• Members of the public will have access to and may reproduce or redistribute my story elsewhere (e.g., on other websites), and HRSA, HHS, and the U.S. Government are not responsible for others’ use of my story.

• It may take time for my story to be posted, or it may not be posted at all.

I warrant that my story does not infringe any copyright or any other right of any third party of which I am aware. I release, discharge, and hold harmless HRSA, HHS, and those acting on their behalf from and against any and all claims that I (or my child if the child is under 18 years old) may have arising from use of my or my child’s story.

By typing my name in the space provided below, I certify that I am authorized to sign for the individual whose story I’m providing -- i.e., The story is my own or my child’s (if the child is under 18 years old), or if the story is of a deceased donor, then I am authorized to sign on his or her behalf.  I certify that the foregoing is true and correct to the best of my knowledge and belief. I intend this electronic signature to have the same effect as my handwritten signature.

To indicate your agreement with the statement above, please type your full name and then click “authorize”. You must be 18 years old or older to submit a story.

Name _________________________

• Authorize

• Submit

To withdraw or edit a published or unpublished story, e-mail your request along with the confirmation number you received upon submission to: xxx@hrsa.gov

Public Burden Statement:  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0915-XXXX.  Public reporting burden for this collection of information is estimated to average 0.68 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-29, Rockville, Maryland, 20857.

Draft Form -- Revised April 8, 2013