Eye Banks

V08_07_14

Attachment 3: TODES DONOR/DONATION DATA REQUESTED FROM EYE BANKS

OMB: XXXX-XXXX

Eye Donors
Eye Donor and Donation Information	COD – Anoxia Cerebrovascular/Stroke Head Trauma CNS Tumor Other (specify)
Donor ID
Eye ID
Date of death
Sex
Age at death: years
Age at death: months
1st person donor designation
NOK or other authorization (verbal or written)
One or more ocular tissues recovered with intent to transplant. Y/N
Donor also an organ donor or at least one organ recovered with intent to transplant. Y/N
Donor also a tissue donor or at least one tissue recovered with intent to transplant. Y/N
Primary COD – per general categories from pull-down menu as shown to the right
Date of death/last time known alive: date
Date of death/last time known alive: time
IN ADDITION, provide eye disposition code for each ocular tissue recovered.

ASSAY RESULTS –list below applies to all donors and qualified referrals. Include all of the following assay results. Include IgG, IgM, and Total Ig results if performed, as well as any and all repeat test results for each assay.

HBsAg Screening Test

HBsAg Confirmatory/Supplemental Test

Anti-HCV Screening Test

Anti-HCV Confirmatory/Supplemental Test

Anti-HIV1/2 Screening Test

Anti-HIV1/2 Confirmatory/Supplemental Test

HIV Ag/Ab combination assay

Anti-HBc (total) Screening Test

Anti-HBc Confirmatory/Supplemental Test

NAT (HIV-1) Screening Test

NAT (HCV) Screening Test

NAT (HIV-1/HCV) Screening Test

NAT (HBV) Screening Test

NAT (HIV-1/HCV/HBV) Screening Test

Sample collection time relative to time of death or last time known alive – (RTI will calculate).

• Provide sample collection date

• Provide sample collection time

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