UMMC Transplant Living Kidney Donor Questionnaire and Referral Form

 

Kidney Donor Information

 
 
 
 
 
Phone
 
 
 
 
 
 
 

Demographics

 
 
 
 
 
 

Medical Information

 
 
 
 
 
 
 

Social Information

 
 
 
 
 
 
 
 

Risk Evaluation Questions

Unexpected transmission of Human Immune Deficiency (HIV), Hepatitis C (HCV), and Hepatitis B Virus (HBV) through organ transmission is a patient safety and public health issue. It is for this reason that, per federal regulations, all potential donors much completed the screening questions below. The results of this evaluation will be kept in the strictest confidence.


In the last 30 days, have you:


  • Had sexual intercourse (vaginal, anal, or oral) with a person known or suspected to have HIV, HCV, HBV?


  • Had sexual intercourse (vaginal, anal, or oral) in exchange for money or drugs?


  • Injected drugs by intravenous, intramuscular, or subcutaneous route for non-medical reasons?


  • Been in lockup, jail, or prison for more than 72 consecutive hours?


  • Had sexual intercourse (vaginal, anal, or oral) with a person who injected drugs by intravenous, intramuscular, or subcutaneous route for non-medical reasons?


  • Had sexual intercourse (vaginal, anal, or oral) with a person who had sex in exchange for money or drugs?
 
 

For men only:

In the last 30 days have you had sexual intercourse (anal or oral) with a man?

 
 

 

Intended Recipient's Information

 
 
 
 
 
 

Consent for Evaluation

By clicking yes in the box below you are given the team consent to review your medical records and evaluate you for donation eligibility.