Form B9 B9_LD NewLivingDonorRecoveries_Clean

Department of Health and Human Services OMB No. 0915-0184

Health Resources and Services Administration Expiration Date: XX/XX/XXXX

Part 4: Living Donor Recoveries

Complete this section if applying for initial approval for living donor recoveries.

Part 4: Section 1 - Other Staff and Resources

1. How does the hospital assess that the short and long term risks for the potential living donor are acceptable to the medical staff at the transplant hospital and the donor? The response needs to address the following: evaluation, consent, surgical risk, and long-term donor considerations.

[Insert response here, table will expand automatically]

2. Mental Health and Social Support Services: Identify the designated members of the transplant team who have primary responsibility for coordinating the psychosocial needs of living donors. Describe their role in this process (insert rows as needed).

Name	Role in Providing Support to Living Donors

3. Does the program have the ability to perform a psychosocial assessment of the donor to:

	Yes	No
Make an informed decision?
Affirm voluntary nature of proceeding with the evaluation and donation?

4. Describe how the program meets the requirement for having an Independent Living Donor Advocate (ILDA) who is not involved with the potential recipient evaluation and who is independent of the decision to transplant the potential recipient.

[Insert response here, table will expand automatically]

Part 4, Section 2 - Living Donor Kidney Only

Kidney Paired Donation (KPD)

1. Will this program participate in the Kidney Paired Donation (KPD) program? If yes, please indicate which matching service will be used.

Yes		No
[Insert detailed response here. Table will expand automatically.]

XX/XX/XXXX Version Living Donor Recoveries - 1