Complete last page: CDC High Risk Screening as define by the U.S. Public Health Services (PHS) Guideline

Please note the family history of all siblings, mother, father, aunts, uncles, cousins, grandmothers, & grandfathers.

U.S. Public Health Service (PHS) High Risk Screening

To ensure St. Luke's recipients do not acquire a kidney that might cause a disease such as HIV or Hepatitis, it is required that living donors be screened for the presence of behaviors that may increase the risk for disease transmission, as defined by the U.S. PHS Guideline. If you answer "yes" to any of the questions below, we are required by law to notify the recipient so that the recipient can understand the risks before the donation.

Please indicate your ethnicity/race (select all that apply)