Common use of PRIVACY AND SECURITY OF INFORMATION Clause in Contracts

PRIVACY AND SECURITY OF INFORMATION. Any information that is obtained about the donor is confidential, and its privacy and security are protected from illegal uses and disclosures in accordance with Federal and Missouri laws. Disclosures will only be made as permitted by law and authorized by the donor or legal representative. AUTHORIZATION FOR DONATION OF BODY Name (Please Print) Street Address: City, State, Zip Code: I hereby donate my body, following my death, to the Department of Pathology and Anatomical Sciences, University of Missouri – Columbia School of Medicine. I have read and understand all of the information contained in this Agreement. The remains of my body shall be cremated and: (Initial applicable statement) Interred at the Memorial Park Cemetery in Columbia, MO, with information about the interment to be provided to (name, address, and phone number): Returned to (name, address, and phone number; please consider identifying several individuals in the event the first named individual cannot be located or has died): I hereby direct that my body be delivered to the University of Missouri–Columbia to be used for educational and research purposed as set forth in this Agreement. Signature of Donor Date Signature of Witness Print Name Relationship to Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the making of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date NOTICE OF REVOCATION OF AUTHORIZATION FOR DONATION OF BODY I, , hereby revoke my Authorization for Donation of Body, effective immediately. Signature of Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the revocation of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date PERSONAL INFORMATION Name: Birthplace (city and state, or foreign country): Date of Birth: Social Security Number: Ever in Armed Forces (yes or no): Xxxxxxx Status (married, never married, widowed, divorced): Surviving Spouse/Domestic Partner name (if different from married name, provide full original name): Usual Occupation (during most of working life; do not list retired): Kind of Business or Industry: Residence - Street and Number: City, Town, or Location: State and Country: Zip Code: Of Hispanic Origin (yes or no - if yes, specify, Cuban, Mexican, Puerto Rican, etc): Race (American Indian, White, Black, etc): Years of Education - Elementary (secondary 0-12): College and/or post-college (1-5 or 5+): Father's Name: First Middle Last Mother's Name: First Middle Last Signature: BRIEF MEDICAL HISTORY Name: First Middle Last Date this Form was Completed: Gender: Sex Assigned at Birth: Date of Birth: Congenital (Inborn) Abnormalities: Abnormalities Acquired Through Injury or Disease: Current Weight: Current Height: Major Surgeries and Approximate Dates: Communicable Diseases (examples include hepatitis, HIV, AIDS, pertussis, rabies, tetanus, Methicillin-resistant staphylococcus aureus [MRSA]): Present State of Health: Additional Information Relating to Physical Condition: GIFT OF BODY PROGRAM AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Xxxxx’s Name: Date of Birth: Address: Phone Number: This Authorization is for the Gift of Body Program (“Program”) at the University of Missouri- Columbia School of Medicine, Department of Pathology and Anatomical Sciences (“University”) to disclose certain information about you if your body is accepted as a gift to the Gift of Body Program. The permissible disclosures may be made to non-University outreach groups for educational purposes only. The following information about you may be disclosed by University: Name; address; age; occupation; minimal medical information; cause of death. This Authorization may be revoked by you at any time in writing to University. This Authorization becomes effective upon signing and will expire five (5) years after your death.

PRIVACY AND SECURITY OF INFORMATION. Any information that is obtained about the donor is confidential, and its privacy and security are protected from illegal uses and disclosures in accordance with Federal and Missouri laws. Disclosures will only be made as permitted by law and authorized by the donor or legal representative. AUTHORIZATION FOR DONATION OF BODY Name (Please Print) Street Address: City, State, Zip Code: I hereby donate my body, following my death, to the Department of Pathology and Anatomical Sciences, University of Missouri – Columbia School of Medicine. I have read and understand all of the information contained in this Agreement. The remains of my body shall be cremated and: (Initial applicable statement) Interred at the Memorial Park Cemetery in Columbia, MO, with information about the interment to be provided to (name, address, and phone number): Returned to (name, address, and phone number; please consider identifying several individuals in the event the first named individual cannot be located or has died): I hereby direct that my body be delivered to the University of Missouri–Columbia to be used for educational and research purposed as set forth in this Agreement. Signature of Donor Date Signature of Witness Print Name Relationship to Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the making of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date NOTICE OF REVOCATION OF AUTHORIZATION FOR DONATION OF BODY I, , hereby revoke my Authorization for Donation of Body, effective immediately. Signature of Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the revocation of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date PERSONAL INFORMATION Name: Birthplace (city and state, or foreign country): Date of Birth: Social Security Number: Ever in Armed Forces (yes or no): Xxxxxxx Status (married, never married, widowed, divorced): Surviving Spouse/Domestic Partner name (if different from married name, provide full original name): Usual Occupation (during most of working life; do not list retired): Kind of Business or Industry: Residence - Street and Number: City, Town, or Location: State and Country: Zip Code: Inside City Limits (yes or no): Years at Present Address: Of Hispanic Origin (yes or no - if yes, specify, Cuban, Mexican, Puerto Rican, etc): Race (American Indian, White, Black, etc): Years of Education - Elementary (secondary 0-12): College and/or post-college (1-5 or 5+): Father's Name: First Middle Last Mother's Name: First Middle Last First Middle Last Signature: BRIEF MEDICAL HISTORY Name: First Middle Last Date this Form was Completed: Gender: Sex Assigned at Birth: Date of Birth: Congenital (Inborn) Abnormalities: Abnormalities Acquired Through Injury or Disease: Current Weight: Current Height: Major Surgeries and Approximate Dates: Communicable Diseases (examples include hepatitis, HIV, AIDS, pertussis, rabies, tetanus, Methicillin-resistant staphylococcus aureus [MRSA]): Present State of Health: Additional Information Relating to Physical Condition: Signature: GIFT OF BODY PROGRAM AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Xxxxx’s Name: Date of Birth: Address: Phone Number: This Authorization is for the Gift of Body Program (“Program”) at the University of Missouri- Columbia School of Medicine, Department of Pathology and Anatomical Sciences (“University”) to disclose certain information about you if your body is accepted as a gift to the Gift of Body Program. The permissible disclosures may be made to non-University outreach groups for educational purposes only. The following information about you may be disclosed by University: Name; address; age; occupation; minimal medical information; cause of death. This Authorization may be revoked by you at any time in writing to University. This Authorization becomes effective upon signing and will expire five (5) years after your death.

PRIVACY AND SECURITY OF INFORMATION. Any information that is obtained about the donor is confidential, and its privacy and security are protected from illegal uses and disclosures in accordance with Federal and Missouri laws. Disclosures will only be made as permitted by law and authorized by the donor or legal representative. AUTHORIZATION FOR DONATION OF BODY Name (Please Print) Street Address: City, State, Zip Code: I hereby donate my body, following my death, to the Department of Pathology and Anatomical Sciences, University of Missouri – Medicine–Columbia School of Medicine. I have read and understand all of the information contained in this Agreement. The remains of my body shall be cremated and: (Initial applicable statement) Interred at the Memorial Park Cemetery in Columbia, MO, with information about the interment to be provided to (name, address, and phone number): Returned to (name, address, and phone number; please consider identifying several individuals in the event the first named individual cannot be located or has died): I hereby direct that my body be delivered to the University of Missouri–Columbia to be used for educational and research purposed as set forth in this Agreement. Signature of Donor Date Signature of Witness Print Name Relationship to Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the making of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date NOTICE OF REVOCATION OF AUTHORIZATION FOR DONATION OF BODY I, , hereby revoke my Authorization for Donation of Body, effective immediately. Signature of Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the revocation of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date PERSONAL INFORMATION Name: Birthplace (city and state, or foreign country): Date of Birth: Social Security Number: Ever in Armed Forces (yes or no): Xxxxxxx Status (married, never married, widowed, divorced): Surviving Spouse/Domestic Partner name (if different from married name, provide full original name): Usual Occupation (during most of working life; do not list retired): Kind of Business or Industry: Residence - Street and Number: City, Town, or Location: State and Country: Zip Code: Inside City Limits (yes or no): Years at Present Address: Of Hispanic Origin (yes or no - if yes, specify, Cuban, Mexican, Puerto Rican, etc): Race (American Indian, White, Black, etc): Years of Education - Elementary (secondary 0-12): College and/or post-college (1-5 or 5+): Father's Name: First Middle Last Mother's Name: First Middle Last Signature: BRIEF MEDICAL HISTORY Name: First Middle Last Date this Form was Completed: Gender: Sex Assigned at Birth: Date of Birth: Congenital (Inborn) Abnormalities: Abnormalities Acquired Through Injury or Disease: Current Weight: Current Height: Major Surgeries and Approximate Dates: Communicable Diseases (examples include hepatitis, HIV, AIDS, pertussis, rabies, tetanus, Methicillin-resistant staphylococcus aureus [MRSA]): Present State of Health: Additional Information Relating to Physical Condition: Signature: GIFT OF BODY PROGRAM AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Xxxxx’s Name: Date of Birth: Address: Phone Number: This Authorization is for the Gift of Body Program (“Program”) at the University of Missouri- Columbia School of Medicine, Department of Pathology and Anatomical Sciences (“University”) to disclose certain information about you if your body is accepted as a gift to the Gift of Body Program. The permissible disclosures may be made to non-University outreach groups for educational purposes only. The following information about you may be disclosed by University: Name; address; age; occupation; minimal medical information; cause of death. This Authorization may be revoked by you at any time in writing to University. This Authorization becomes effective upon signing and will expire five (5) years after your death.

PRIVACY AND SECURITY OF INFORMATION. Any information that is obtained about the donor is confidential, and its privacy and security are protected from illegal uses and disclosures in accordance with Federal and Missouri laws. Disclosures will only be made as permitted by law and authorized by the donor or legal representative. AUTHORIZATION FOR DONATION OF BODY Name (Please Print) Street Address: City, State, Zip Code: I hereby donate my body, following my death, to the Department of Pathology and Anatomical Sciences, University of Missouri – Columbia School of Medicine. I have read and understand all of the information contained in this Agreement. The remains of my body shall be cremated and: (Initial applicable statement) Interred at the Memorial Park Cemetery in Columbia, MO, with information about the interment to be provided to (name, address, and phone number): Returned to (name, address, and phone number; please consider identifying several individuals in the event the first named individual cannot be located or has died): I hereby direct that my body be delivered to the University of Missouri–Columbia to be used for educational and research purposed as set forth in this Agreement. Signature of Donor Date Signature of Witness Print Name Relationship to Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the making of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date NOTICE OF REVOCATION OF AUTHORIZATION FOR DONATION OF BODY I, , hereby revoke my Authorization for Donation of Body, effective immediately. Signature of Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the revocation of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date PERSONAL INFORMATION Name: Birthplace (city and state, or foreign country): Date of Birth: Social Security Number: Ever in Armed Forces (yes or no): Xxxxxxx Status (married, never married, widowed, divorced): Surviving Spouse/Domestic Partner name (if different from married name, provide full original name): Usual Occupation (during most of working life; do not list retired): Kind of Business or Industry: Residence - Street and Number: City, Town, or Location: State and Country: Zip Code: Inside City Limits (yes or no): Years at Present Address: Of Hispanic Origin (yes or no - if yes, specify, Cuban, Mexican, Puerto Rican, etc): Race (American Indian, White, Black, etc): Years of Education - Elementary (secondary 0-12): College and/or post-college (1-5 or 5+): Father's Name: First Middle Last Mother's Name: First Middle Last Signature: BRIEF MEDICAL HISTORY Name: First Middle Last Date this Form was Completed: Gender: Sex Assigned at Birth: Date of Birth: Congenital (Inborn) Abnormalities: Abnormalities Acquired Through Injury or Disease: Current Weight: Current Height: Major Surgeries and Approximate Dates: Communicable Diseases (examples include hepatitis, HIV, AIDS, pertussis, rabies, tetanus, Methicillin-resistant staphylococcus aureus [MRSA]): Present State of Health: Additional Information Relating to Physical Condition: Signature: GIFT OF BODY PROGRAM AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Xxxxx’s Name: Date of Birth: Address: Phone Number: This Authorization is for the Gift of Body Program (“Program”) at the University of Missouri- Columbia School of Medicine, Department of Pathology and Anatomical Sciences (“University”) to disclose certain information about you if your body is accepted as a gift to the Gift of Body Program. The permissible disclosures may be made to non-University outreach groups for educational purposes only. The following information about you may be disclosed by University: Name; address; age; occupation; minimal medical information; cause of death. This Authorization may be revoked by you at any time in writing to University. This Authorization becomes effective upon signing and will expire five (5) years after your death.

PRIVACY AND SECURITY OF INFORMATION. Any information that is obtained about the donor is confidential, and its privacy and security are protected from illegal uses and disclosures in accordance with Federal and Missouri laws. Disclosures will only be made as permitted by law and authorized by the donor or legal representative. AUTHORIZATION FOR DONATION OF BODY Name (Please Print) Street Address: City, State, Zip Code: I hereby donate my body, following my death, to the Department of Pathology and Anatomical Sciences, University of Missouri – Medicine–Columbia School of Medicine. I have read and understand all of the information contained in this Agreement. The remains of my body shall be cremated and: (Initial applicable statement) Interred at the Memorial Park Cemetery in Columbia, MO, with information about the interment to be provided to (name, address, and phone number): Returned to (name, address, and phone number; please consider identifying several individuals in the event the first named individual cannot be located or has died): I hereby direct that my body be delivered to the University of Missouri–Columbia to be used for educational and research purposed as set forth in this Agreement. Signature of Donor Date Signature of Witness Print Name Relationship to Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the making of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date NOTICE OF REVOCATION OF AUTHORIZATION FOR DONATION OF BODY I, , hereby revoke my Authorization for Donation of Body, effective immediately. Signature of Donor Date If the Donor is physically unable to sign this Authorization, another individual may sign this Authorization which shall be witnessed by two adults, at least one of which shall be a disinterested witness. A “disinterested witness” is a person other than the Donor’s spouse, child, parent, sibling, grandparent, grandchild, or guardian. By signing below, you are indicating that the Donor has authorized and directed the revocation of this anatomical gift. Signature of Individual Signing at the Direction of Donor Date _ Signature of Disinterested Witness Date Signature of Witness Date PERSONAL INFORMATION Name: Birthplace (city and state, or foreign country): Date of Birth: Social Security Number: Ever in Armed Forces (yes or no): Xxxxxxx Status (married, never married, widowed, divorced): Surviving Spouse/Domestic Partner name (if different from married name, provide full original name): Usual Occupation (during most of working life; do not list retired): Kind of Business or Industry: Residence - Street and Number: City, Town, or Location: State and Country: Zip Code: Inside City Limits (yes or no): Years at Present Address: Of Hispanic Origin (yes or no - if yes, specify, Cuban, Mexican, Puerto Rican, etc): Race (American Indian, White, Black, etc): Years of Education - Elementary (secondary 0-12): College and/or post-college (1-5 or 5+): Father's Name: First Middle Last Mother's Name: First Middle Last First Middle Last Signature: BRIEF MEDICAL HISTORY Name: First Middle Last Date this Form was Completed: Gender: Sex Assigned at Birth: Date of Birth: Congenital (Inborn) Abnormalities: Abnormalities Acquired Through Injury or Disease: Current Weight: Current Height: Major Surgeries and Approximate Dates: Communicable Diseases (examples include hepatitis, HIV, AIDS, pertussis, rabies, tetanus, Methicillin-resistant staphylococcus aureus [MRSA]): Present State of Health: Additional Information Relating to Physical Condition: Signature: GIFT OF BODY PROGRAM AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Xxxxx’s Name: Date of Birth: Address: Phone Number: This Authorization is for the Gift of Body Program (“Program”) at the University of Missouri- Columbia School of Medicine, Department of Pathology and Anatomical Sciences (“University”) to disclose certain information about you if your body is accepted as a gift to the Gift of Body Program. The permissible disclosures may be made to non-University outreach groups for educational purposes only. The following information about you may be disclosed by University: Name; address; age; occupation; minimal medical information; cause of death. This Authorization may be revoked by you at any time in writing to University. This Authorization becomes effective upon signing and will expire five (5) years after your death.