Form 5 Donor Histocompatibility

Records
Donor Histocompatibility Worksheet
The revised worksheet sample is for reference purposes only and is pending OMB approval.
B.

Note: These worksheets are provided to function as a guide to what data will be required in the online TIEDI application.
Currently in the worksheet, a red asterisk is displayed by fields that are required, independent of what other data may be
B.

provided. Based on data provided through the online TIEDI application, additional fields that are dependent on responses
provided in these required fields may become required as well. However, since those fields are not required in every case,
they are not marked with a red asterisk.

Donor ID:
Provider Information
Lab:
OPO:

Donor Information
Donor Name:
UNOS Donor ID #:
Donor Type:

Donor Center Histocompatibility Typing
Donor HLA Typed:

j YES n
k
l
m
n
j NO n
k
l
m
j UNK
k
l
m

Date Typing Complete Class I:

c Peripheral Blood
d
e
f
g
c Lymph Nodes
d
e
f
g
Target Source for Class I:

c Spleen
d
e
f
g
c Thymocytes
d
e
f
g
c Cell lines/clonal cells
d
e
f
g
c Solid Matrix
d
e
f
g

c Serology g
d
e
f
g
c DNA
d
e
f
A (1)

A (2)

B(1)

B (2)

Bw4
Typing Method Class I:

Bw6

Cw (1)

Cw (2)

Date Typing Complete Class II:

c Peripheral Blood
d
e
f
g
c Lymph Nodes
d
e
f
g
Target Source for Class II:

c Spleen
d
e
f
g
c Thymocytes
d
e
f
g
c Cell lines/clonal cells
d
e
f
g
c Solid Matrix
d
e
f
g

c Serology g
d
e
f
g
c DNA
d
e
f
DR (1)

DR (2)

Typing Method Class II:

DR51

DR52

DR53

DQ (2)

DPW (1)

DPW (2)

Recipient of a Living Donor Information
Name:
SSN:
Organ Type:
Transplant Date:
Transplant Center:

j 0
k
l
m
n
j .5
k
l
m
n
j 1
k
l
m
n
Haplotype Match:

j 1.5
k
l
m
n
j 2
k
l
m
n
j N/A Living Donor - Not Typed
k
l
m
n
j N/A Unrelated Donor
k
l
m
n
j UNKNOWN
k
l
m
n