1 Deceased Donor Registration

Records
Deceased Donor Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 08/31/2007
®

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 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:
Donor Information
OPO:
Donor Hospital:
Referral Date:

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

Recovered Outside the U.S.:
Country:

Last Name:

First Name:

MI:

DOB:

j Months n
k
l
m
n
j Years
k
l
m

Age:

Gender:
Home City:

j Male n
k
l
m
n
j Female
k
l
m
State:

Zip Code:
-

Ethnicity/Race:
American Indian or Alaska Native

Asian

c American Indian
d
e
f
g

g Asian Indian/Indian Sub-Continent
c
d
e
f

c Eskimo
d
e
f
g

c Chinese
d
e
f
g

c Aleutian
d
e
f
g

c Filipino
d
e
f
g

c Alaska Indian
d
e
f
g

c Japanese
d
e
f
g

c American Indian or Alaska Native: Other
d
e
f
g

g Korean
c
d
e
f

c American Indian or Alaska Native: Not Specified/Unknown
d
e
f
g

c Vietnamese
d
e
f
g
c Asian: Other
d
e
f
g
c Asian: Not Specified/Unknown
d
e
f
g

Black or African American

Hispanic/Latino

c African American
d
e
f
g

c Mexican
d
e
f
g

c African (Continental)
d
e
f
g

c Puerto Rican (Mainland)
d
e
f
g

c West Indian
d
e
f
g

c Puerto Rican (Island)
d
e
f
g

c Haitian
d
e
f
g

g Cuban
c
d
e
f

c Black or African American: Other
d
e
f
g

c Hispanic/Latino: Other
d
e
f
g

c Black or African American: Not Specified/Unknown
d
e
f
g

c Hispanic/Latino: Not Specified/Unknown
d
e
f
g

Native Hawaiian or Other Pacific Islander

White

c Native Hawaiian
d
e
f
g

g European Descent
c
d
e
f

c Guamanian or Chamorro
d
e
f
g

c Arab or Middle Eastern
d
e
f
g

c Samoan
d
e
f
g

c North African (non-Black)
d
e
f
g

c Native Hawaiian or Other Pacific Islander: Other
d
e
f
g

c White: Other
d
e
f
g

c Native Hawaiian or Other Pacific Islander: Not Specified/Unknown
d
e
f
g

g White: Not Specified/Unknown
c
d
e
f

i U.S. CITIZEN
j
k
l
m
n
Citizenship:

j RESIDENT ALIEN
k
l
m
n
j NON-RESIDENT ALIEN, Specify Country
k
l
m
n

Home Country:

j ANOXIA
k
l
m
n
j CEREBROVASCULAR/STROKE
k
l
m
n
Cause of Death:

j HEAD TRAUMA
k
l
m
n
j CNS TUMOR
k
l
m
n
j OTHER SPECIFY
k
l
m
n

Specify:

j DROWNING
k
l
m
n
j SEIZURE
k
l
m
n
j DRUG INTOXICATION
k
l
m
n
j ASPHYXIATION
k
l
m
n
j CARDIOVASCULAR
k
l
m
n

j ELECTRICAL
k
l
m
n
j GUNSHOT WOUND
k
l
m
n
j STAB
k
l
m
n
j BLUNT INJURY
k
l
m
n

Mechanism of Death:

j SIDS
k
l
m
n
j INTRACRANIAL HEMORRHAGE/STROKE
k
l
m
n
j DEATH FROM NATURAL CAUSES
k
l
m
n
j NONE OF THE ABOVE
k
l
m
n

j MVA
k
l
m
n
j SUICIDE
k
l
m
n
j HOMICIDE
k
l
m
n
j CHILD-ABUSE
k
l
m
n

Circumstances of Death:

j NON-MVA
k
l
m
n
j DEATH FROM NATURAL CAUSES
k
l
m
n
j NONE OF THE ABOVE
k
l
m
n

Procurement and Consent

j NO
k
l
m
n
j YES, MEDICAL EXAMINER CONSENTED
k
l
m
n

Medical Examiner/Coroner:

j YES, MEDICAL EXAMINER REFUSED CONSENT
k
l
m
n

j UNKNOWN
k
l
m
n
Did the patient have written documentation of their intent to be a
donor:

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

If yes, indicate mechanisms (check all that apply):

c Driver's license
d
e
f
g

c Donor Card
d
e
f
g

c Donor Registry
d
e
f
g

c Durable Power of Attorney / Healthcare Proxy
d
e
f
g
Other Specify
Was the consent based solely on this documentation:

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

Did the patient express to family or others the intent to be a donor:

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

Date and time of pronouncement of death: (Complete for brain dead
and DCD donors):

Date:

Time:

(military time)

Date and time consent obtained for first organ:

Date:

Time:

(military time)

Clinical Information
ABO Blood Group:

Height:

ft

Weight:

lbs

in

cm

kg

Terminal Lab Data:
Serum Creatinine:

mg/dl

ST=

BUN:

mg/dl

ST=

Total Bilirubin:

mg/dl

ST=

SGOT/AST:

u/L

ST=

SGPT/ALT:

u/L

ST=

Protein in Urine:
Last Serum Sodium Prior to Procurement:

j UNK
k
l
m
j YES n
k
l
m
n
j NO n
k
l
m
mEq/L

ST=

INR:

ST=

Blood PH:

ST=

Hematocrit:

%

ST=

Pancreas (PA Donors Only):
Serum Lipase:

u/L

ST=

Serum Amylase:

u/L

ST=

Serology:

ST=

ST=

j Positive
k
l
m
n
j Negative
k
l
m
n
Anti-HIV I/II:

j Unknown
k
l
m
n
j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

Anti-HTLV I/II:

j Unknown
k
l
m
n

j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n
RPR-VDRL:

j Unknown
k
l
m
n
j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

Anti-CMV:

j Unknown
k
l
m
n
j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

HBsAg:

j Unknown
k
l
m
n
j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

Anti-HBc:

j Unknown
k
l
m
n
j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

Anti-HCV:

j Unknown
k
l
m
n
j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

HBsAb:

j Unknown
k
l
m
n
j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

j Unknown
k
l
m
n
EBV (VCA) (lgG):

j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n

EBV (VCA) (lgM):

j Unknown
k
l
m
n
j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n

j Indeterminate
k
l
m
n
j Positive
k
l
m
n
j Negative
k
l
m
n
j Unknown
k
l
m
n

EBNA:

j Cannot Disclose
k
l
m
n
j Not Done
k
l
m
n
j Indeterminate
k
l
m
n
Donor Management: (Any medications administered within 24 hours prior to crossclamp.)
Steroids:

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

Diuretics:

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

T3:

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

T4:

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

Anticonvulsants:

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

Antihypertensives:

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

Vasodilators:

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

DDAVP:

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

Heparin:

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

Arginine Vasopressin:

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

Insulin:

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

Other/Specify:
Other/Specify:
Other/Specify:

Inotropic Medications at Time of Cross Clamp:

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

j Dopamine
k
l
m
n
j Dobutamine
k
l
m
n
j Epinephrine
k
l
m
n
Medication:

j Levophed
k
l
m
n

Specify:

j Neosynephrine
k
l
m
n
j Isoproterenol (Isuprel)
k
l
m
n
j Other, specify
k
l
m
n
Dosage Units:

j mcg/kg/min
k
l
m
n
j mcg/min
k
l
m
n
Dosage At Time of Cross Clamp:

j mg/min
k
l
m
n
j units/hr
k
l
m
n
j mcg/hr
k
l
m
n

Final Dosage Duration:

hours

j Dopamine
k
l
m
n

j Dobutamine
k
l
m
n
j Epinephrine
k
l
m
n
Medication:

j Levophed
k
l
m
n

Specify:

j Neosynephrine
k
l
m
n
j Isoproterenol (Isuprel)
k
l
m
n
j Other, specify
k
l
m
n
Dosage Units:

j mcg/kg/min
k
l
m
n
j mcg/min
k
l
m
n
Dosage At Time of Cross Clamp:

j mg/min
k
l
m
n
j units/hr
k
l
m
n
j mcg/hr
k
l
m
n

Final Dosage Duration:

hours

j Dopamine
k
l
m
n

j Dobutamine
k
l
m
n
j Epinephrine
k
l
m
n
Medication:

j Levophed
k
l
m
n

Specify:

j Neosynephrine
k
l
m
n
j Isoproterenol (Isuprel)
k
l
m
n
j Other, specify
k
l
m
n
Dosage Units:

j mcg/kg/min
k
l
m
n
j mcg/min
k
l
m
n
Dosage At Time of Cross Clamp:

j mg/min
k
l
m
n
j units/hr
k
l
m
n
j mcg/hr
k
l
m
n

Final Dosage Duration:

hours

j NONE
k
l
m
n
j 1-5
k
l
m
n
Number of transfusions during this (terminal) hospitalization:

j 6 - 10
k
l
m
n
j GREATER THAN 10
k
l
m
n
j UNKNOWN
k
l
m
n

Three or more inotropic agents at time of incision:

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

Clinical Infection:

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

Source

Confirmed by Culture

c
d
e
f
g

Blood

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

c
d
e
f
g

Lung

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

c
d
e
f
g

Urine

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

c
d
e
f
g

Other

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

Other, specify:

Lifestyle Factors
Cigarette Use (> 20 pack years) - Ever:

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

AND continued in last six months:

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

Cocaine Use - Ever:

AND continued in last six months:

Other Drug Use (non - IV) - Ever:

AND continued in last six months:

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

Heavy Alcohol Use (heavy= 2+ drinks/day):

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

Tattoos:

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

Does the Donor meet CDC guidelines for "High Risk" for an organ
donor:

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

j NO
k
l
m
n
j YES, 0-5 YEARS
k
l
m
n
j YES, 6-10 YEARS
k
l
m
n

History of Diabetes:

j YES, >10 YEARS
k
l
m
n
j YES, DURATION UNKNOWN
k
l
m
n
j UNKNOWN
k
l
m
n
j NO
k
l
m
n
j YES, 0-5 YEARS
k
l
m
n
j YES, 6-10 YEARS
k
l
m
n

Insulin Dependent:

j YES, >10 YEARS
k
l
m
n
j YES, DURATION UNKNOWN
k
l
m
n
j UNKNOWN
k
l
m
n
j NO
k
l
m
n

j YES, 0-5 YEARS
k
l
m
n
j YES, 6-10 YEARS
k
l
m
n

History of Hypertension:

j YES, >10 YEARS
k
l
m
n
j YES, UNKNOWN DURATION
k
l
m
n
j UNKNOWN
k
l
m
n
If yes, method of control:
Diet:

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

Diuretics:

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

Other Hypertensive Medication:

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

History of Cancer:
Specify:
Cancer Free Interval:

years

ST=

Organ Recovery
Recovery Date (donor to OR):

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

Was this a DCD donor:

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

If Yes, Controlled:
If Yes, Date and time of withdrawal of support:
If Yes, Date and time agonal phase begins (systolic BP < 80 or
O2 sat. < 80%:

Date:

Time:

(military time)

Date:

Time:

(military time)

If DCD, Total urine output during OR recovery phase:
Measures Between Withdrawal of Support and Cardiac Death. Provide Serial Data Every 15 Minutes Between Withdrawal of Support and Start of Agonal Phase, and Every
5 Minutes Between Start of Agonal Phase and Cardiac Death.
Date:

Time (military time):

Systolic blood pressure:

If Yes, Core Cooling Used:

Diastolic blood pressure:

Mean arterial pressure:

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

If Yes, Date and time of abdominal aorta cannulation:

Date:

Time:

(military time)

ST=

If Yes, Date and time of thoracic aorta cannulation:

Date:

Time:

(military time)

ST=

If Yes, Date and time of portal vein cannulation:

Date:

Time:

(military time)

ST=

If Yes, Date and time of pulmonary artery cannulation:

Date:

Time:

(military time)

ST=

Estimated Warm Ischemic Time:

If No, Was this a consented DCD donor that progressed to brain
death?

min

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

ST=

O2 saturation:

Cardiac arrest since neurological event that led to declaration of
brain death:

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

If Yes, Duration of Resuscitation:

min

ST=

Clamp Date:
Clamp Time: (Military Time)

ST=

j Eastern
k
l
m
n
j Central
k
l
m
n
j Mountain
k
l
m
n
Clamp Time Zone:

j Pacific
k
l
m
n
j Alaska
k
l
m
n
j Hawaii
k
l
m
n

j Atlantic
k
l
m
n
All Donors Cardiac and Pulmonary Function:
History of previous MI:

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

LV ejection fraction (%):

ST=

j Echo
k
l
m
n
Method:

j MUGA
k
l
m
n
j Angiogram
k
l
m
n
j No
k
l
m
n
j Yes, normal
k
l
m
n

Coronary Angiogram:

j Yes, not normal
k
l
m
n
j 0 n
k
l
m
n
j 1 n
k
l
m
j 2 n
k
l
m
j 3 n
k
l
m
j Unknown
k
l
m

If Abnormal, # of Vessels with > 50% Stenosis:

Pulmonary Measurements:
Lung - Was pO2 done:

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

If Yes, Lung pO2 terminal value:

mm/Hg

ST=

If Yes, Lung pO2 on FiO2 terminal value of:
pCO2:

Was a pulmonary artery catheter placed:

mm/Hg

ST=

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

If Yes, Initial (baseline) and Final-Preoperative measurements:
Initial

Final

Map: (mm/Hg)

ST=

ST=

CVP: (mm/Hg)

ST=

ST=

PCWP: (mm/Hg)

ST=

ST=

SVR: (dynes/sec/cm)^5)

ST=

ST=

PA Systolic: (mm/Hg)

ST=

ST=

PA Diastolic: (mm/Hg)

ST=

ST=

CO: (L/min)

ST=

ST=

Cardiac Index: (L/min/sq.m)

ST=

ST=

j NO
k
l
m
n
Biopsy (heart donors only):

j YES, MYOCARDITIS
k
l
m
n
j YES, NEGATIVE BIOPSY RESULT
k
l
m
n
j YES, OTHER DIAGNOSIS SPECIFY
k
l
m
n

Other Diagnosis /Specify:

Left Kidney Biopsy:

j YES n
k
l
m
n
j NO
k
l
m
j 0-5
k
l
m
n
j 6-10
k
l
m
n

Glomerulosclerosis:

j 11-15
k
l
m
n
j 16-20
k
l
m
n

j 20+
k
l
m
n
j Indeterminate
k
l
m
n
Pump:

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

Final Resistance Prior to Shipping:
Transferred to transplant center on pump:

Right Kidney Biopsy:

ST=

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

j YES n
k
l
m
n
j NO
k
l
m
j 0-5
k
l
m
n
j 6-10
k
l
m
n

Glomerulosclerosis:

j 11-15
k
l
m
n
j 16-20
k
l
m
n

j 20+
k
l
m
n
j Indeterminate
k
l
m
n
Pump:

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

Final Resistance Prior to Shipping:
Transferred to transplant center on pump:

Liver Biopsy:

ST=

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

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

% Macro vesicular fat:

%

ST=

% Micro/intermediate vesicular fat:

%

ST=

Other Histology (check all that apply):

c Hemosidera:
d
e
f
g
c Granulomas:
d
e
f
g
Other Specify:

j No Bronchoscopy
k
l
m
n
j Bronchoscopy Results normal
k
l
m
n

j Bronchoscopy Results, Abnormal-purulent secretions
k
l
m
n
Left Lung Bronchoscopy:

j Bronchoscopy Results, Abnormal-aspiration of foreign body
k
l
m
n
j Bronchoscopy Results, Abnormal-blood
k
l
m
n
j Bronchoscopy Results, Abnormal-anatomy/other lesion
k
l
m
n
j Bronchoscopy Results, Unknown
k
l
m
n
j Unknown if bronchoscopy performed
k
l
m
n
j No Bronchoscopy
k
l
m
n
j Bronchoscopy Results normal
k
l
m
n
j Bronchoscopy Results, Abnormal-purulent secretions
k
l
m
n

Right Lung Bronchoscopy:

j Bronchoscopy Results, Abnormal-aspiration of foreign body
k
l
m
n
j Bronchoscopy Results, Abnormal-blood
k
l
m
n
j Bronchoscopy Results, Abnormal-anatomy/other lesion
k
l
m
n
j Bronchoscopy Results, Unknown
k
l
m
n
j Unknown if bronchoscopy performed
k
l
m
n
j No chest x-ray
k
l
m
n
j Normal
k
l
m
n
j Abnormal-left
k
l
m
n

Chest X-ray:

j Abnormal-right
k
l
m
n

j Abnormal-both
k
l
m
n
j Results Unknown
k
l
m
n
j Unknown if chest x-ray performed
k
l
m
n

Organ Dispositions
Right Kidney

j Consent Not Requested
k
l
m
n

j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time right kidney recovered/removed from donor:

Date:

Time:

(military time)

Time:

(military time)

Time:

(military time)

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Left Kidney

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time left kidney recovered/removed from donor:

Date:

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Double Enbloc Kidney

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time double/en-bloc kidney recovered/removed
from donor:

Date:

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Pancreas

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time whole pancreas recovered/removed from
donor:

Date:

Time:

(military time)

Time:

(military time)

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Pancreas Segment 1

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time pancreas segment 1 recovered/removed from
donor:
Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:

Date:

Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Pancreas Segment 2

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time pancreas segment 2 recovered/removed from
donor:

Date:

Time:

(military time)

Time:

(military time)

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Liver

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time whole liver recovered/removed from donor:
Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Liver Segment 1

Date:

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time liver segment 1 recovered/removed from
donor:

Date:

Time:

(military time)

Time:

(military time)

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Liver Segment 2

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time liver segment 1 recovered/removed from
donor:

Date:

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Intestine

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time whole intestine recovered/removed from
donor:

Date:

Time:

(military time)

Time:

(military time)

Time:

(military time)

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Intestine Segment 1

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time whole intestine recovered/removed from
donor:

Date:

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Intestine Segment 2

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time whole intestine recovered/removed from
donor:
Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:

Date:

Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Heart

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time heart recovered/removed from donor:

Date:

Time:

(military time)

Time:

(military time)

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Left Lung

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time left lung recovered/removed from donor:
Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Date:

Right Lung

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n
j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n

If DCD Date and time right lung recovered/removed from donor:

Date:

Time:

(military time)

Time:

(military time)

Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

Double Lung

j Consent Not Requested
k
l
m
n
j Consent Not Obtained
k
l
m
n
j Organ Not Recovered
k
l
m
n
Organ:

j Recovered Not for Tx
k
l
m
n

j Recovered for TX but Not Tx
k
l
m
n
j Transplanted
k
l
m
n
j N/A
k
l
m
n
If DCD Date and time double/en-bloc lung recovered/removed from
donor:
Recipient:
SSN:
TX Center:
Reason Code:
Specify:
Reason organ not transplanted:
Specify:
Recovery Team#:
Initial Flush Solution:
Specify:
Back Table Flush Solution:
Specify:
Final Flush/Storage Solution:
Specify:

UNOS View Only
Comments:

Date: