NEW YORK ORGAN DONOR NETWORK
PERSONAL STORIES INFORMATION SHEET
TRANSPLANT RECIPIENT FROM A DECEASED DONOR
4 Easy Steps to Submit Your Story:
1. Save this Word document to your computer.
2. Fill out the form and add pages if you need to.
3. Upon completion, please fax form to the Communications Department
at (646) 291-4600 or email communications@nyodn.org.
4. If you wish to attach a few photos, please ensure they are in the JPEG
format and are no larger than 150 KB.
1.
Today’s date
2.
Your name:
3.
Address, phone numbers (home, work and cell) and email:
4.
Age today:
5.
Race/ethnicity
6.
Religion
7.
Marital status/children, etc.
8.
What was the illness that led to the transplant and for how long?
9.
Duration on waiting list:
10. Organ(s)/tissue(s) received:
11. Date of transplant:
12. Which transplant center?
(Page 1 of 2)
January 2013
13. Age when transplanted:
14. Type of work and where before the transplant:
15. Interests/hobbies:
16. How is your health currently?
17. What are you doing now? (Work, sports, hobbies, etc.)
18. What do you know about the deceased donor?
19. If you have made contact with your donor family in some way, please explain:
20. What does the transplant mean to you?
21. What does your donor mean to you?
22. Additional notes (Add pages)
(Page 2 of 2)
January 2013