1 SRTR Initial Registration Worksheet_20171208_updates

Scientific Registry of Transplant Recipients Information Collection Effort for Potential Donors for Living Organ Donation (SRTR)

SRTR Initial Registration Worksheet_20171208_updates

Scientific Registry of Transplant Recipients Information Collection Effort for Potential Donors for Living Organ Donation

OMB: 0906-0034

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Living Donor and Potential Living Donor Initial Registration Worksheet

(Kidney and Liver)

Provider Information

1. Donor Center:


Donor Candidate Information

2. Living Donor Collective (LDC) ID Number: ____________

3. UNOS Donor ID Number (if/when assigned): ____________

4. Donor Candidate Name: ___________________________

5. Address: ________________________________________

___________________________________________

City: ____________________

State: ____________________

Zip Code: ________________________

6. Mailing Address: ___________________

____________________________

City: ____________________

State: ____________________

Zip Code: ________________________

7. Primary Phone: ________________________

8. Secondary Phone: ______________________________

9. Primary Email: ________________________________

10. Secondary Email: ________________________________

11. SSN#: ____________________

11a. 9FN if no SSN: _______________________________

12. Date of Birth: _____________________________________

13. Whom can we contact if we cannot reach the donor candidate? (Only to obtain donor contact information; no other information will be shared)

Name: _____________________________

Address: ___________________________

City: _______________________________

State: _______________________________

Phone 1:___________________________

Phone 2:___________________________

Email: _____________________________

Relationship to donor candidate: ____________________


13a. Preferred method of contact:

  • Primary phone

    • Text

    • Voice

  • Secondary phone

  • Primary email

  • Secondary email

  • Postal Mail

  • Other, Specify:

  • Social Media: Specify (Facebook, Twitter, Instagram, etc.):


14. Gender:

  • Male

  • Female


15. Marital Status at Time of Donation:

  • Single

  • Married

  • Divorced

  • Separated

  • Life Partner

  • Widowed

  • Unknown


16. Donor Candidate Type:

  • Biological, blood related Parent

  • Biological, blood related Child

  • Biological, blood related Identical Twin

  • Biological, blood related Full Sibling

  • Biological, blood related Half Sibling

  • Biological, blood related Other Relative

  • Non-Biological, Spouse

  • Non-Biological, Life Partner

  • Non-Biological, Unrelated: Paired Donation

  • Non-Biological, Unrelated: Non-Directed Donation (Anonymous)

  • Non-Biological, Living/Deceased Donation

  • Non-Biological, Unrelated: Domino

  • Non-Biological, Other Unrelated Directed Donation

  • Non-Biological, Other



17. Ethnicity/Race: (select all origins that apply)

  • American Indian or Alaska Native

  • American Indian

  • Eskimo

  • Aleutian

  • Alaska Indian

  • American Indian or Alaska Native: Other

  • American Indian or Alaska Native: Not Specified/Unknown

  • Asian

  • Asian Indian/Indian Sub-Continent

  • Chinese

  • Filipino

  • Japanese

  • Korean

  • Vietnamese

  • Asian: Other

  • Asian: Not Specified/Unknown

  • Black or African American

  • African American

  • African (Continental)

  • West Indian

  • Haitian

  • Black or African American: Other

  • Black or African American: Not Specified/Unknown

  • Hispanic/Latino

  • Mexican

  • Puerto Rican (Mainland)

  • Puerto Rican (Island)

  • Cuban

  • Hispanic/Latino: Other

  • Hispanic/Latino: Not Specified/Unknown

  • Native Hawaiian or Other Pacific Islander

  • Native Hawaiian

  • Guamanian or Chamorro

  • Samoan

  • Native Hawaiian or Other Pacific Islander: Other

  • Native Hawaiian or Other Pacific Islander: Not Specified/Unknown

  • White

  • European Descent

  • Arab or Middle Eastern

  • North African (non-Black)

  • White: Other

  • White: Not Specified/Unknown


18. Citizenship:

  • US Citizen

  • Non-US Citizen/US Resident

  • Non-US Citizen/Non-US Resident, Traveled to US for Reason Other Than Transplant

  • Non-US Citizen/Non-US Resident, Traveled to US for Transplant

Country of Permanent Residence: ___________________________

Year of Entry into U.S.: _____________________________

19. Highest Education Level:

  • None

  • Grade school (0-8)

  • High school (9-12) or GED

  • Attended college/technical school

  • Associate/Bachelor degree

  • Post-college graduate degree

  • Unknown


20. Does the Candidate have health insurance?

  • YES

  • NO

  • UNKNOWN


21. Working for Income:

  • YES

If Yes (check one):

  • Working Full Time

  • Working Part Time due to Disability

  • Working Part Time due to Insurance Conflict

  • Working Part Time due to Inability to Find Full Time Work

  • Working Part Time due to Donor Choice

  • Working Part Time Reason Unknown

  • Working, Part Time vs. Full Time Unknown

  • NO

  • UNKNOWN

If Not Working, Reason (check one):

  • Disability

  • Insurance Conflict

  • Inability to Find Work

  • Donor Choice - Homemaker

  • Donor Choice - Student Full Time/Part Time

  • Donor Choice - Retired

  • Donor Choice - Other

  • UNKNOWN



22. Household Income:

  • $0 to $19,999

  • $20,000 to $24,999

  • $25,000 to $29,999

  • $30,000 to $34,999

  • $35,000 to $39,999

  • $40,000 to $44,999

  • $45,000 to $54,999

  • $55,000 to $74,999

  • $75,000 to $99,999

  • $100,000 or above

  • Refused

  • Don’t know

23. Number of individuals living in the household: ___

Pre-Donation Clinical Information


Date of initial in-clinic screening for living donation: _____________


24. Pre-Donation Height and Weight

Height: ___ ft ___ in, or ___ cm

Weight: ___ lb, or ___ kg


25. History of Cancer (check all that apply):

  • NO

  • Lip

  • Other oral cavity/pharynx

  • Esophagus

  • Stomach

  • Colon and rectum

  • Anus

  • Liver

  • Pancreas

  • Lung

  • Melanoma

  • Squamous Cell Skin

  • Breast

  • Uterine Cervix

  • Corpus and Uterus

  • Prostate

  • Testis

  • Urinary Bladder

  • Kidney and Renal Pelvis

  • Brain and Other Nervous System

  • Thyroid

  • Hodgkin Lymphoma

  • Non-Hodgkin Lymphoma

  • Myeloma

  • Leukemia

  • Other, Specify:___________________


Cancer Free Interval: ___ years


26. History of Tobacco Use:

  • YES

  • NO

If YES,

Number of cigarettes per day: ____

__________ Number of years smoked: ______ (Pack years will auto-calculate.)

Duration of Abstinence from Cigarettes:

  • None, still smoking

  • 0-2 months

  • 3-12 months

  • 1.1-3.0 years

  • 3.1-5.0 years

  • >5.0 years

  • UNKNOWN


27. Other Tobacco Used:

  • YES

  • NO

  • UNKNOWN


28. History of Marijuana Use (check one):

  • Never

  • More than 5 years ago

  • Occasional use

  • Regular use

  • Declined or do not know.


29. Diabetes:

  • YES

  • NO

  • UNKNOWN

Treatment of Diabetes (check all that apply):

  • Insulin

  • Oral Hypoglycemic Agent

  • Diet

  • None


30. Is Candidate currently taking a cholesterol-lowering medication?

  • NO

  • YES, indicate either or both:

    • Statin

    • Other cholesterol-lowering medication

  • UNKNOWN


31. Was the Candidate ever told by a doctor or other health professional that he/she has/had hypertension (check one):

  • NO

  • 5 YEARS

  • 6-10 YEARS

  • >10 YEARS

  • UNKNOWN DURATION

  • UNKNOWN

If history of hypertension, is/was medication used to control blood pressure (check one):

  • None

  • 1 medication for blood pressure

  • 2 medications for blood pressure

  • More than 2 medications for blood pressure

  • UNKNOWN


32. Clinic Blood Pressure at the time of donor evaluation:

Systolic: ___ mm Hg

Diastolic: ___ mm Hg


33. 24-hour Ambulatory Blood Pressure obtained (check one):

  • Yes

  • No


34. Cholesterol and Glucose:

Total cholesterol: ___ mg/dL

High density lipoprotein (HDL) cholesterol: ___ mg/dL

Low density lipoprotein (LDL) cholesterol: ___ mg/dL

Triglycerides: ___ mg/dL

Fasting blood glucose: ___ mg/dL


35. Donation Information

Organ candidate will donate:

  • Liver

  • Kidney

Date of Donation:

  • Date of Decision to Not Donate:

  • Date of donation:



36. Does registrant agree to be contacted by LDC in the future?

  • Yes

  • No


Pre-Donation Liver Clinical Information (Provide only if a liver donor candidate)

L1. Total Bilirubin: ___ mg/dL

L2. SGOT/AST: ___ U/L

L3. SGPT/ALT: ___ U/L

L4. Alkaline Phosphatase: ___ units/L

L5. Serum Albumin: ___ g/dL

L6. Serum Creatinine: ___ mg/dL

L7. INR: ___

L8. Platelet Count: ______per microliter (mcL)


L9. Liver Biopsy:

  • NO (not done)

  • YES

% Macro vesicular fat: ___ %

% Micro vesicular fat: ___ %


L10. Did the Candidate ever have hepatitis, jaundice or elevated liver tests, or was the Candidate ever told by a health care provider that he/she had hepatitis, jaundice or abnormal liver tests?

  • YES

  • NO

  • UNKNOWN

L11. In the past 12 months, how often did the Candidate drink any type of alcoholic beverage? How many days per week, per month, or per year did the Candidate drink? Enter ‘0’ for never. Enter

  • |__| days per week, or

  • |__| days per month, or

  • |__| days per year.

  • Declined or don’t know

L 12. In the past 12 months, on those days that the Candidate drank alcoholic beverages, on the average, how many drinks did the Candidate have? Enter

  • |__|number of drinks, and if less than 1 drink, enter ‘1’.

  • Declined or don’t know


Pre-Donation Kidney Clinical Information (Provide only if a kidney donor candidate)

K1. Urine Albumin-Creatinine Ratio: ___ mg/g

K2. Serum Uric Acid: ___ mg/dL

K3. Serum Creatinine: ___ mg/dL


K4. APOL1 risk if Candidate is African American (check one):

  • 0 risk variants

  • 1 risk variant

  • 2 risk variants

  • Not measured

  • UNKNOWN


K5. Family history of kidney disease (check one):

  • NO

  • Biologic parent

  • Child

  • Brother or sister

  • Other blood relative

  • UNKNOWN


Type of kidney disease in the family (check all that apply):

  • Kidney disease known to be caused by diabetes

  • Kidney disease known to be caused by high blood pressure

  • Autosomal dominant polycystic kidney disease (ADPKD or PKD)

  • Alport syndrome or thin basement membrane disease/nephropathy

  • Atypical hemolytic uremic syndrome (aHUS)

  • Fabry disease

  • Familial focal segmental glomerulosclerosis

  • Other hereditary kidney disease

  • None of the above

  • UNKNOWN


K6. Has a doctor or other health professional ever told the Candidate that he/she had gout?

  • YES

  • NO

  • UNKNOWN


K7. Family history of diabetes (check one):

  • NO

  • Biologic parent

  • Child

  • Brother or sister

  • UNKNOWN


K8. Has a doctor or other health professional ever told the Candidate that he/she had kidney stones?

  • YES

  • NO

  • UNKNOWN

If yes, how many times has the Candidate passed a kidney stone (choose one)?

  • 0 (never)

  • 1

  • 2

  • 3-5

  • >5

  • UNKNOWN

Most recent kidney stone:

  • Never

    • < 2 years ago

  • 2-5 years ago

  • 5-10 years ago

  • >10 years ago


K9. Have you ever been pregnant? Y/N/Male

During any pregnancy:

Was the Candidate ever told by a doctor or other health professional that she had diabetes, sugar diabetes or gestational diabetes? Please do not include diabetes that candidate may have known about before the pregnancy:

  • YES

  • NO

  • UNKNOWN


Was the Candidate ever told by a doctor or other health professional that she had Gestational Hypertension?

  • YES

  • NO

  • UNKNOWN


Was the Candidate ever told by a doctor or other health professional that she had Preeclampsia (Hypertension with Proteinuria during Pregnancy)?

  • YES

  • NO

  • UNKNOWN

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