Form 1 Donor Histocompatibility

Records
Donor Histocompatibility 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:
Provider Information
Lab:
OPO:

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

Donor Center Histocompatibility Typing
Donor HLA Typed:

YES

NO

UNK

Date Typing Complete Class I:

Peripheral Blood
Lymph Nodes
Spleen
Target Source for Class I:
Thymocytes
Cell lines/clonal cells
Solid Matrix

Typing Method Class I:

Serology

DNA

A

A

B

B

Bw4

Bw6

Cw

Cw

Date Typing Complete Class II:

Peripheral Blood
Lymph Nodes
Spleen
Target Source for Class II:
Thymocytes
Cell lines/clonal cells
Solid Matrix

Typing Method Class II:

Serology
DR

DNA

DR

DR51

DR52

DR53

DQ (1)

DQ (2)

DPB

DPB

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

0
.5
1
Haplotype Match:

1.5
2
N/A Living Donor - Not Typed
N/A Unrelated Donor

UNKNOWN

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Comments: