Form 1 Deceased Donor Registration

Records
Deceased Donor Registration Worksheet
FORM APPROVED: O.M.B. NO. 0915-0157 Expiration Date: 12/31/2011
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:
Recovered Outside the U.S.:

YES

NO

Country:

Last Name:

First Name:

MI:

DOB:
Age:

Months

Gender:
Home City:

Male

Female

State:

Zip Code:
-

Ethnicity/Race:
American Indian or Alaska Native
American Indian

Asian
Asian Indian/Indian SubContinent

Eskimo
Chinese
Aleutian
Filipino
Alaska Indian
Japanese
American Indian or Alaska Native: Other
Korean
American Indian or Alaska Native: Not
Specified/Unknown

Vietnamese

Years

Asian: Other
Asian: Not Specified/Unknown
Black or African American

Hispanic/Latino

African American

Mexican

African (Continental)

Puerto Rican (Mainland)

West Indian

Puerto Rican (Island)

Haitian

Cuban

Black or African American: Other

Hispanic/Latino: Other

Black or African American: Not Specified/Unknown
Native Hawaiian or Other Pacific Islander

Hispanic/Latino: Not
Specified/Unknown
White

Native Hawaiian

European Descent

Guamanian or Chamorro

Arab or Middle Eastern

Samoan

North African (non-Black)

Native Hawaiian or Other Pacific Islander: Other

White: Other

Native Hawaiian or Other Pacific Islander: Not
Specified/Unknown

White: Not Specified/Unknown

U.S. CITIZEN
Citizenship:

RESIDENT ALIEN
NON-RESIDENT ALIEN, Specify Country

Home Country:

ANOXIA
CEREBROVASCULAR/STROKE
Cause of Death:

HEAD TRAUMA
CNS TUMOR
OTHER SPECIFY

Specify:

DROWNING
SEIZURE
ASPHYXIATION
ELECTRICAL
STAB
SIDS
Mechanism of Death:

DEATH FROM NATURAL CAUSES
DRUG INTOXICATION
CARDIOVASCULAR
GUNSHOT WOUND
BLUNT INJURY
INTRACRANIAL HEMORRHAGE/STROKE
NONE OF THE ABOVE

MVA
SUICIDE
HOMICIDE
Circumstances of Death:

CHILD-ABUSE
NON-MVA
DEATH FROM NATURAL CAUSES
NONE OF THE ABOVE

Procurement and Consent

NO
Medical Examiner/Coroner:
YES, MEDICAL EXAMINER CONSENTED

YES, MEDICAL EXAMINER REFUSED CONSENT
UNKNOWN
Did the patient have written documentation of
their intent to be a donor:

YES

NO

UNK

If yes, indicate mechanisms (check all that apply):
Driver's license

Donor Card

Donor Registry

Durable Power of Attorney / Healthcare
Proxy
Other Specify
Was the consent based solely on this
documentation:

YES

NO

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

YES

NO

UNK

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

Date:

Time:

(military time)

Date and time consent obtained for organ
donation:

Date:

Time:

(military time)

Clinical Information
ABO Blood Group:

Height:
Weight:

ft

in

lbs

cm

ST=

kg

ST=

Terminal Lab Data:
Serum Creatinine:
BUN:
Total Bilirubin:
SGOT/AST:
SGPT/ALT:

Protein in Urine:

mg/dl

ST=

mg/dl

ST=

mg/dl

ST=

u/L

ST=

u/L

ST=

YES

NO

UNK

Last Serum Sodium Prior to Procurement:

mEq/L

ST=

INR:

ST=

Blood pH:
Hematocrit:

ST=
%

ST=

Pancreas (PA Donors Only):
Serum Lipase:
Serum Amylase:

u/L

ST=

u/L

ST=

Serology:

Positive
Negative
Unknown
Anti-HIV I/II:
Cannot Disclose
Not Done
Indeterminate

Positive
Negative
Unknown
Anti-HTLV I/II:
Cannot Disclose
Not Done
Indeterminate

Positive
Negative
RPR-VDRL:
Unknown
Cannot Disclose

Not Done
Indeterminate

Positive
Negative
Unknown
Anti-CMV:
Cannot Disclose
Not Done
Indeterminate

Positive
Negative
Unknown
HBsAg:
Cannot Disclose
Not Done
Indeterminate

Positive
Negative
Unknown
Anti-HBc:
Cannot Disclose
Not Done
Indeterminate

Positive
Anti-HCV:

Negative
Unknown

Cannot Disclose
Not Done
Indeterminate

Positive
Negative
Unknown
HBsAb:
Cannot Disclose
Not Done
Indeterminate

Positive
Negative
Unknown
EBV (VCA) (lgG):
Cannot Disclose
Not Done
Indeterminate

Positive
Negative
Unknown
EBV (VCA) (lgM):
Cannot Disclose
Not Done
Indeterminate

Positive
EBNA:
Negative

Unknown
Cannot Disclose
Not Done
Indeterminate

Donor Management: (Any medications administered within 24 hours prior to crossclamp.)
Steroids:

Diuretics:

T3:

T4:

Anticonvulsants:

Antihypertensives:

Vasodilators:

DDAVP:

Heparin:

Arginine Vasopressin:

Insulin:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

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

Inotropic Medications at Time of Cross Clamp:

Dopamine
Dobutamine
Epinephrine
Medication:

Levophed

Specify:

Neosynephrine
Isoproterenol (Isuprel)
Other, specify
Dosage Units:
mcg/kg/min
mcg/min
Dosage at Time of Cross Clamp:
mg/min
units/hr
mcg/hr
Final Dosage Duration:

hours

Dopamine
Dobutamine
Epinephrine
Medication:

Levophed

Specify:

Neosynephrine
Isoproterenol (Isuprel)
Other, specify
Dosage Units:
mcg/kg/min
Dosage at Time of Cross Clamp:
mcg/min
mg/min

units/hr
mcg/hr
Final Dosage Duration:

hours

Dopamine
Dobutamine
Epinephrine
Medication:

Levophed

Specify:

Neosynephrine
Isoproterenol (Isuprel)
Other, specify
Dosage Units:
mcg/kg/min
mcg/min
Dosage at Time of Cross Clamp:
mg/min
units/hr
mcg/hr
Final Dosage Duration:

hours

NONE
1-5
Number of transfusions during this (terminal)
hospitalization:

6 - 10
GREATER THAN 10
UNKNOWN

Three or more inotropic agents at time of
incision:

YES

NO

Clinical Infection:
Source

YES

NO

UNK

Confirmed by Culture

Blood

YES

NO

Lung

YES

NO

Urine

YES

NO

Other

YES

NO

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

Other, specify:

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

AND continued in last six months:

Cocaine Use - Ever:

AND continued in last six months:

Other Drug Use (non - IV) - Ever:

AND continued in last six months:

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

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

NO
History of Diabetes:
YES, 0-5 YEARS

YES, 6-10 YEARS
YES, >10 YEARS
YES, DURATION UNKNOWN
UNKNOWN

NO
YES, 0-5 YEARS
YES, 6-10 YEARS
Insulin Dependent:
YES, >10 YEARS
YES, DURATION UNKNOWN
UNKNOWN

NO
YES, 0-5 YEARS
YES, 6-10 YEARS
History of Hypertension:
YES, >10 YEARS
YES, UNKNOWN DURATION
UNKNOWN
If yes, method of control:
Diet:

Diuretics:

Other anti-hypertensive medication:

History of Cancer:
Specify:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

Cancer Free Interval:

years

ST=

Cancer at time of procurement:
Intracranial:

YES

NO

UNK

YES

NO

UNK

YES

NO

UNK

YES

NO

Extracranial:

Skin:

Organ Recovery
Recovery Date (donor to OR):

Was this a DCD donor:

If Yes, Controlled:

YES

If Yes, Date and time of withdrawal of support:

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

NO

UNK

Date:

Time:
time)

(military

Date:

Time:
time)

(military

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 Card iac
Death.
Date:

Time (military
time):

Systolic blood
pressure:

If Yes, Core Cooling Used:

Diastolic blood
pressure:

YES

Mean arterial
pressure:

O2
saturation:

NO

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?

Cardiac arrest since neurological event that led
to declaration of brain death:
If Yes, Duration of Resuscitation:

min

YES

YES

ST=

NO

NO

min

ST=

Clamp Date:
Clamp Time: (Military Time)

ST=

Eastern
Central
Mountain
Clamp Time Zone:

Pacific
Alaska
Hawaii
Atlantic

All Donors Cardiac and Pulmonary Function:
History of previous MI:

YES

NO

LV ejection fraction (%):

ST=

Echo
Method:

MUGA
Angiogram

If LV, Ejection Fraction < 50%:
Structural Abnormalities:
Valves:

UNK

YES

NO

Congenital:

LVH:

YES

NO

YES

NO

YES

NO

YES

NO

Wall Abnormalities:
Segmental:

Global:

No
Coronary Angiogram:

Yes, normal
Yes, not normal

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

0

1

2

3

Unknown

Pulmonary Measurements:
Lung - Was pO2 done:

YES

If Yes, Lung pO2 terminal value:

NO

UNK

mm/Hg

ST=

If Yes, Lung pO2 on FiO2 terminal value of:

PCO2

mm/Hg

Was a pulmonary artery catheter placed:

YES

ST=

NO

If Yes, Initial (baseline) and Final-Preoperative measurements:
Initial
MAP: (mm Hg)
CVP: (mm Hg)
PCWP: (mm Hg)
SVR: ((dynes/sec/cm)^5)
PA Systolic: (mm Hg)

Final
ST=

ST=

ST=

ST=

ST=

ST=

ST=

ST=

ST=

ST=

PA Diastolic: (mm Hg)
CO: (L/min)
Cardiac Index: (L/min/sq.m)

ST=

ST=

ST=

ST=

ST=

ST=

NO
YES, MYOCARDITIS
Biopsy (heart donors only):
YES, NEGATIVE BIOPSY RESULT
YES, OTHER DIAGNOSIS SPECIFY
Other Diagnosis /Specify:

Left Kidney Biopsy:

YES

NO

0-5
6-10
11-15
Glomerulosclerosis:
16-20
20+
Indeterminate

Pump:

YES

NO

Final Resistance Prior to Shipping:

Transferred to transplant center on pump:

Right Kidney Biopsy:

Glomerulosclerosis:

ST=

YES

NO

YES

NO

0-5

6-10
11-15
16-20
20+
Indeterminate

Pump:

YES

NO

Final Resistance Prior to Shipping:

Transferred to transplant center on pump:

Liver Biopsy:

% Macro vesicular fat:
% Micro/intermediate vesicular fat:
Other Histology (check all that apply):

ST=

YES

NO

YES

NO

%

ST=

%

ST=

Hemosidera:
Granulomas:
Other Specify:

No Bronchoscopy
Bronchoscopy Results normal
Bronchoscopy Results, Abnormal-purulent secretions
Bronchoscopy Results, Abnormal-aspiration of foreign body
Left Lung Bronchoscopy:
Bronchoscopy Results, Abnormal-blood
Bronchoscopy Results, Abnormal-anatomy/other lesion
Bronchoscopy Results, Unknown
Unknown if bronchoscopy performed

No Bronchoscopy
Bronchoscopy Results normal
Bronchoscopy Results, Abnormal-purulent secretions
Bronchoscopy Results, Abnormal-aspiration of foreign body
Right Lung Bronchoscopy:
Bronchoscopy Results, Abnormal-blood
Bronchoscopy Results, Abnormal-anatomy/other lesion
Bronchoscopy Results, Unknown
Unknown if bronchoscopy performed

No chest x-ray
Normal
Abnormal-left
Chest X-ray:

Abnormal-right
Abnormal-both
Results Unknown
Unknown if chest x-ray performed

Organ Dispositions

Right Kidney

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:
Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted

N/A
If DCD, date and time right kidney
recovered/removed from donor:

Date:

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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Left Kidney

Consent Not Requested
Consent Not Obtained
Organ:

Organ Not Recovered
Recovered Not for Tx
Recovered for TX but Not Tx

(military time)

Transplanted
N/A
If DCD, date and time left kidney
recovered/removed from donor:

Date:

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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Double En Bloc Kidney

Consent Not Requested
Consent Not Obtained
Organ:
Organ Not Recovered
Recovered Not for Tx

(military time)

Recovered for TX but Not Tx
Transplanted
N/A
If DCD, date and time double/en-bloc kidney
recovered/removed from donor:

Date:

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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Pancreas

Consent Not Requested
Organ:

Consent Not Obtained
Organ Not Recovered

(military time)

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A
If DCD, date and time whole pancreas
recovered/removed from donor:

Date:

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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Pancreas Segment 1

Consent Not Requested
Organ:
Consent Not Obtained

(military time)

Organ Not Recovered
Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A
If DCD, date, and time pancreas segment 1
recovered/removed from donor:

Date:

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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Pancreas Segment 2
Organ:

Consent Not Requested

(military time)

Consent Not Obtained
Organ Not Recovered
Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A
If DCD, date and time pancreas segment 2
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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Liver

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Liver Segment 1

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

If DCD, date and time liver segment 1
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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Liver Segment 2

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

If DCD, date and time liver segment 2
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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Intestine

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

If DCD, date and time whole intestine
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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Intestine Segment 1

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

If DCD, date and time intestine segment 1
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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Intestine Segment 2

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

If DCD, date and time intestine segment 2
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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Heart

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

If DCD, date and time heart
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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Left Lung

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Right Lung

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

If DCD, date and time right 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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

Double Lung

Date:

Time:

(military time)

Consent Not Requested
Consent Not Obtained
Organ Not Recovered
Organ:

Recovered Not for Tx
Recovered for TX but Not Tx
Transplanted
N/A

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:
OPO sent vessels with organ:
Were extra vessels used in the transplant
procedure:
Vessel Donor ID:

UNOS View Only

Date:

Time:

(military time)

Comments: