— Body Donation Investigation - Next-of-Kin Questionnaire

Next-of-Kin First Name

Next-of-Kin Last Name

Next-of-Kin Date of Birth mm/dd/yyyy

Address 1

Address 2

City

State

Country

ZIP/Postal Code

Primary Telephone Number

Secondary Telephone Number

E-Mail Address:

Relationship to Donor

Donor First Name

Donor Last Name

Donor Date of Death mm/dd/yyyy

Victim Identification Number (VIN) If you received a Victim Notification Letter, your VIN can be found there.

1. To which company was your loved one's body donated? Select all that apply.

Biological Resource Center of Illinois (BRCIL)

Biological Resource Center (Phoenix, Arizona)

Anatomical Service, Inc. (ASI)

Arthroscopy Association of North America

International Biological, Inc.

Other

2. If you answered other to question 1, please specify.

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4. If you answered yes to question 3, please provide name and affiliation.

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5. Did you/the donor receive any literature via mail, e-mail, or fax about the company? Select all that apply.

Yes (Mail)

Yes (E-mail)

Yes (Fax)

No

I don't know

6. Were you/the donor informed that the company would not sell the donation and/or that it was illegal for the company to sell human body parts?

Yes
No
I don't know

7. If you answered yes to question 6, please explain how you/the donor were informed. Phone call from company representative, in person, via e-mail, website, literature, etc.

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8. Were you/the donor told how the donation would be used?

Yes
No
I don't know

9. If you answered yes to question 8, what kind of information did you/the donor receive?

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10. Did the company tell you/the donor about alternative options for families having financial difficulties covering final expenses? e.g., county public fiduciary program, state indigent burial program

Yes
No
I don't know

11. Was the donation made at least partly because of financial hardship with covering final expenses?

Yes
No
I don't know

12. Was there a Power of Attorney (POA) or Medical Power of Attorney (MPOA) on file for the donor?

Yes
No
I don't know

13. Would you like someone from the FBI to contact you to discuss this issue further?

Yes
No

Privacy Act Statement

The FBI is authorized to collect the information on this form by one or more of the following provisions: Title 28, United States Code, sections 533 and 534; Title 28, Code of Federal Regulations, section 0.85; and the Attorney General Guidelines for Victim and Witness Assistance. The information requested will assist the FBI in providing you with assistance to which crime victims are entitled under federal law. You do not have to provide the requested information; however, failure to do so may hinder the FBI in providing you with crime victim assistance. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code section 552a, and is maintained in the FBI’s Central Records System, DOJ/FBI-002, a description of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998) and which may be viewed at www.justice.gov/opcl/privacyact.html#doj.

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Body Donation Investigation - Next-of-Kin Questionnaire