OPOs

v08_07_14

Attachment 2: TODES DONOR/DONATION DATA REQUESTED FROM OPOs

OMB: XXXX-XXXX

Organ Donors	Referrals	Tissue Donors
Donor and Organ Information for Donors in OPTN	Referral Information for those not in OPTN Local ID Donor ID Tissue ID Eye ID Date of death Time of death Sex Age at death: years Age at death: months 1st person donor designation NOK or other authorization (verbal or written) Donor is a tissue donor or at least one tissue recovered with intent to transplant. Y/N Donor is an ocular donor or at least one ocular tissue recovered with intent to transplant. Y/N	Tissue Donor and Tissue Information
Local ID		Local ID
Donor ID (UNOS)		Donor ID
Tissue ID		Tissue ID
Eye ID		Eye ID
Date of death		Date of death
Sex		Sex
Age at death: years		Age at death: years
Age at death: months		Age at death: months
Donor also a tissue donor or at least one tissue recovered with intent to transplant. Y/N		1st person donor designation
Donor also an ocular donor or at least one ocular tissue recovered with intent to transplant. Y/N		NOK or other authorization (verbal or written)
		One or more tissues recovered with intent to transplant. Y/N
One or more organs 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 an ocular donor or at least one ocular tissue recovered with intent to transplant. Y/N
	Primary COD – per general categories from pull-down menu as shown to the right	Primary COD – per general categories from pull-down menu as shown to the right	COD – Anoxia Cerebrovascular/Stroke Head Trauma CNS Tumor Other (specify)
	Cross-clamp date	Date of death/last time known alive: date
	Cross-clamp time
	DCD Donor – date of death	Date of death/last time known alive: time
	DCD Donor – time of death
	High Risk or Increased Risk Y/N/Not Done
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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