2 Living Donor Registration Form.xlsx

			Living Donor Registration (LDR)
			Fields to be completed by members
			Form Section	Field Label	Notes
			1-Provider Information	Recipient Center Name	Display Only
			1-Provider Information	Center Code Type	Display Only - Cascades from Database
			1-Provider Information	Center Code	Display Only - Cascades from Database
			2-Donor Information	Donor Last Name	Display Only - Cascades from Database
			2-Donor Information	Donor First Name	Display Only - Cascades from Database
			2-Donor Information	UNOS Donor ID #	Display Only - Cascades from feedback
			2-Donor Information	Home Address
			2-Donor Information	Home City
			2-Donor Information	Home State
			2-Donor Information	Home Zip
			2-Donor Information	Home Phone
			2-Donor Information	Work Phone	Not required
			2-Donor Information	Email	Not required
			2-Donor Information	Donor SSN
			2-Donor Information	Donor Date of Birth
			2-Donor Information	Donor Gender//Gender
			2-Donor Information	Marital Status at Time of Donation
			2-Donor Information	ABO Blood Group	Display Only - Cascades from Database
			2-Donor Information	Living Donor Type
			2-Donor Information	Living Donor Type Other Specify
			2-Donor Information	Ethnicity/Race
			2-Donor Information	Citizenship
			2-Donor Information	Year of Entry into U.S.
			2-Donor Information	Country of Permanent Residence
			2-Donor Information	Highest Education Level
			2-Donor Information	Did the donor have health insurance
			2-Donor Information	Functional Status
			2-Donor Information	Physical Capacity: (check one)
			2-Donor Information	Working for Income
			2-Donor Information	Working for Income//If No, Not Working Due To: (check one)
			2-Donor Information	Working for Income//If Yes
			2-Donor Information	% Macro vesicular fat
			2-Donor Information	% Micro vesicular fat
			3-Pre-Donation Clinical Information	Viral Detection://Have any of the following viruses ever been tested for: HIV, CMV, HBV, HCV, EBV
			3-Pre-Donation Clinical Information	HIV Status
			3-Pre-Donation Clinical Information	CMV Total	Not required
			3-Pre-Donation Clinical Information	CMV//IgG
			3-Pre-Donation Clinical Information	CMV//IgM
			3-Pre-Donation Clinical Information	CMV//Nucleic Acid Testing	Not required
			3-Pre-Donation Clinical Information	HBV
			3-Pre-Donation Clinical Information	HBV//Core Antibody
			3-Pre-Donation Clinical Information	HBV//Surface Antigen
			3-Pre-Donation Clinical Information	HBV//HBV/DNA (NAT/PCR)
			3-Pre-Donation Clinical Information	HCV
			3-Pre-Donation Clinical Information	HCV//Antibody
			3-Pre-Donation Clinical Information	HCV//RIBA
			3-Pre-Donation Clinical Information	HCV//HCV/RNA (NAT/PCR)
			3-Pre-Donation Clinical Information	EBV Total
			3-Pre-Donation Clinical Information	EBV//IgG
			3-Pre-Donation Clinical Information	EBV//IgM
			3-Pre-Donation Clinical Information	Pre-Donation//Height
			3-Pre-Donation Clinical Information	Pre-Donation Height//Status
			3-Pre-Donation Clinical Information	Pre-Donation//Weight
			3-Pre-Donation Clinical Information	Pre-Donation Weight//Status
			3-Pre-Donation Clinical Information	History of Cancer
			3-Pre-Donation Clinical Information	History of Cancer Specify//Specify	Value or status is reported, not both
			3-Pre-Donation Clinical Information	Cancer Free Interval
			3-Pre-Donation Clinical Information	Cancer Free Interval //Status	Value or status is reported, not both
			4-Pre_Donation Clinical Information	History of Cigarette Use
			4-Pre_Donation Clinical Information	History of Cigarette Use Pack Years//If Yes, Check # pack years
			4-Pre_Donation Clinical Information	Duration of Abstinence
			4-Pre_Donation Clinical Information	Other Tobacco Used	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Total Bilirubin
			4-Pre-Donation Liver Clinical Information	Total Bilirubin//Status
			4-Pre-Donation Liver Clinical Information	SGOT/AST
			4-Pre-Donation Liver Clinical Information	SGOT/AST//Status
			4-Pre-Donation Liver Clinical Information	SGPT/ALT
			4-Pre-Donation Liver Clinical Information	SGPT/ALT//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Alkaline Phosphatase
			4-Pre-Donation Liver Clinical Information	Alkaline Phosphatase//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Serum Albumin
			4-Pre-Donation Liver Clinical Information	Serum Albumin//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Serum Creatinine
			4-Pre-Donation Liver Clinical Information	Serum Creatinine//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	INR
			4-Pre-Donation Liver Clinical Information	INR//Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	Liver Biopsy
			4-Pre-Donation Liver Clinical Information	% Macro/intermediate vesicular fat //Status	Value or status is reported, not both
			4-Pre-Donation Liver Clinical Information	% Micro/intermediate vesicular fat //Status
			3-Pre-Donation Kidney Clinical Information	History of Hypertension
			3-Pre-Donation Kidney Clinical Information	History of Hypertension Diet
			3-Pre-Donation Kidney Clinical Information	History of Hypertension Diuretics	Display Only - Cascades from Database
			3-Pre-Donation Kidney Clinical Information	History of Hypertension Other Hypertensive Medication
			3-Pre-Donation Kidney Clinical Information	Diabetes
			3-Pre-Donation Kidney Clinical Information	Diabetes Treatment
			3-Pre-Donation Kidney Clinical Information	Kidney Preoperative Creatinine//Serum Creatinine
			3-Pre-Donation Kidney Clinical Information	Kidney Preoperative Creatinine//Status
			3-Pre-Donation Kidney Clinical Information	Preoperative Blood Pressure Systolic
			3-Pre-Donation Kidney Clinical Information	Preoperative Blood Pressure Systolic//Status
			3-Pre-Donation Kidney Clinical Information	Preoperative Blood Pressure Diastolic
			3-Pre-Donation Kidney Clinical Information	Preoperative Blood Pressure Diastolic//Status	Value or status is reported, not both
			3-Pre-Donation Kidney Clinical Information	Urinalysis	Display Only
			3-Pre-Donation Kidney Clinical Information	Preoperative Urinalysis//Urine Protein	Value or status is reported, not both
			3-Pre-Donation Kidney Clinical Information	Preoperative Urinalysis//Protein-Creatinine Ratio
			3-Pre-Donation Lung Clinical Information	Diabetes
			3-Pre-Donation Lung Clinical Information	Diabetes Treatment
			5-Pre-Donation lung Clinical Information	FVC % predicted before//FVC % predicted	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FVC % predicted before//Status
			5-Pre-Donation lung Clinical Information	FVC % predicted after//FVC % predicted	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FVC % predicted after//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FEV1 % predicted before//FEV1 % predicted
			5-Pre-Donation lung Clinical Information	FEV1 % predicted before//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FEV1 % predicted after//FEV1 % predicted
			5-Pre-Donation lung Clinical Information	FEV1 % predicted after//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FEF (25-75%) % predicted before//FEF (25-75%) % predicted
			5-Pre-Donation lung Clinical Information	FEF (25-75%) % predicted before//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	FEF (25-75%) % predicted after//FEF (25-75%) % predicted
			5-Pre-Donation lung Clinical Information	FEF (25-75%) % predicted after//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	TLC % predicted before//TLC % predicted
			5-Pre-Donation lung Clinical Information	TLC % predicted before//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	TLC % predicted after//TLC % predicted
			5-Pre-Donation lung Clinical Information	TLC % predicted after//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	Diffusing lung capacity corrected for alveolar volume % predicted
			5-Pre-Donation lung Clinical Information	Diffusing lung capacity corrected for alveolar volume % predicted//Status	Value or status is reported, not both
			5-Pre-Donation lung Clinical Information	PaO2 on room air
			5-Pre-Donation lung Clinical Information	PaO2 on room air//Status	Value or status is reported, not both
			Liver Surgical Information	Type of Transplant Graft
			Kidney Surgical Information	Kidney//Type of Transplant Graft	Display Only - Cascades from Database
			Kidney Surgical Information	Kidney//Intended Procedure Type	Value or status is reported, not both
			Kidney Surgical Information	Conversion from Laparoscopic to Open
			Lung Surgical Information	Lung//Type of Transplant Graft	Display Only - Cascades from Database
			Lung Surgical Information	Lung//Procedure Type	Value or status is reported, not both
			Lung Surgical Information	Conversion from Thoracoscopic to Open
			Lung Surgical Information	Intra-operative Complications
			Lung Surgical Information	Intra-operative Complications Specify//If Yes, Specify
			Lung Surgical Information	Sacrifice of Second Lobe, Specify
			Lung Surgical Information	Anesthetic Complication Specify
			Lung Surgical Information	Arrhythmia requiring therapy
			Lung Surgical Information	Intra-operative Complications Other//Other Specify
			6-Post-Operative Information	Date of Initial Discharge
			6-Post-Operative Information	Donor Status
			6-Post-Operative Information	Date Last Seen or Death
			6-Post-Operative Information	Cause of Death
			6-Post-Operative Information	Cause of Death//Other Specify
			6-Post-Operative Information	Non-Autologous Blood Administration
			6-Post-Operative Information	PRBC Units//If Yes, Number of Units
			6-Post-Operative Information	Platelets Units//If Yes, Number of Units
			6-Post-Operative Information	FF Units//If Yes, Number of Units
			8-Liver Related Post-Operative Complications	Biliary Complications
			8-Liver Related Post-Operative Complications	Biliary Complications//If Yes, Specify
			8-Liver Related Post-Operative Complications	Biliary Complications//If Yes, Specify://Date of surgery
			8-Liver Related Post-Operative Complications	Liver Vascular Complications Requiring Intervention//Vascular Complications Requiring Intervention
			8-Liver Related Post-Operative Complications	Liver Vascular Complications//If Yes, Specify
			8-Liver Related Post-Operative Complications	Liver Vascular Complications Other//Specify
			8-Liver Related Post-Operative Complications	Liver Other Complications Requiring Intervention
			8-Liver Related Post-Operative Complications	Liver Other Complications//If Yes, Specify
			8-Liver Related Post-Operative Complications	Liver Other Complications Other//Specify
			8-Liver Related Post-Operative Complications	Liver Reoperation
			8-Liver Related Post-Operative Complications	Reoperation//If yes, specify reason for reoperation (during first six weeks)
			8-Liver Related Post-Operative Complications	Liver Reoperation Liver Failure
			8-Liver Related Post-Operative Complications	Liver Reoperation Liver Failure Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Bleeding Complications
			8-Liver Related Post-Operative Complications	Liver Reoperation Bleeding Date//Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Hernia Repair
			8-Liver Related Post-Operative Complications	Liver Reoperation Hernia Repair Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Bowel Obstruction
			8-Liver Related Post-Operative Complications	Liver Reoperation Bowel Obstruction Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Vascular Complications
			8-Liver Related Post-Operative Complications	Liver Reoperation Vascular Date
			8-Liver Related Post-Operative Complications	Liver Reoperation Other//Other Specify
			8-Liver Related Post-Operative Complications	Liver Reoperation Other Specify//Other Specify
			8-Liver Related Post-Operative Complications	Liver Reoperation Other Date
			8-Liver Related Post-Operative Complications	Liver Readmission//Any Readmission After Initial Discharge
			8-Liver Related Post-Operative Complications	Liver Readmission Reason//If yes, specify reason for readmission (during first six weeks)
			8-Liver Related Post-Operative Complications	Liver Readmission Reason Other//Other Specify
			8-Liver Related Post-Operative Complications	Liver Readmission Date//If Yes, Date of First Readmission
			8-Liver Related Post-Operative Complications	Liver Other Interventional Procedures
			8-Liver Related Post-Operative Complications	Liver Other Interventional Procedures//If Yes, Specify Procedure
			8-Liver Related Post-Operative Complications	Liver Other Interventional Procedures Date//Date of Procedure
			7-Kidney Related Post-Operative Complications	Kidney Vascular Complications Requiring Intervention//Vascular Complications Requiring Intervention
			7-Kidney Related Post-Operative Complications	Kidney Vascular Complications//If Yes, Specify
			7-Kidney Related Post-Operative Complications	Kidney Vascular Complications Other//Specify
			7-Kidney Related Post-Operative Complications	Kidney Other Complications Requiring Intervention//Other Complications Requiring Intervention
			7-Kidney Related Post-Operative Complications	Kidney Other Complications//If Yes, Specify
			7-Kidney Related Post-Operative Complications	Kidney Other Complications Other//Other Specify
			7-Kidney Related Post-Operative Complications	Kidney Reoperation//Reoperation
			7-Kidney Related Post-Operative Complications	Reoperation//If yes, specify reason for reoperation (during first six weeks)
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Bleeding//Bleeding
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Bleeding Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Hernia Repair//Hernia Repair
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Hernia Repair Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Bowel Obstruction//Bowel Obstruction
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Bowel Obstruction Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Vascular//Vascular
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Vascular Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Other//Other Specify
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Other Specify//Other Specify
			7-Kidney Related Post-Operative Complications	Kidney Reoperation Other Date//Date
			7-Kidney Related Post-Operative Complications	Kidney Readmission//Any Readmission After Initial Discharge
			7-Kidney Related Post-Operative Complications	Kidney Readmission Reason//If yes, specify reason for readmission (during first six weeks)
			7-Kidney Related Post-Operative Complications	Kidney Readmission Reason Other//Other Specify
			7-Kidney Related Post-Operative Complications	Kidney Readmission Date//If Yes, Date of First Readmission
			7-Kidney Related Post-Operative Complications	Kidney Other Interventional Procedures//Other Interventional Procedures
			7-Kidney Related Post-Operative Complications	Kidney Other Interventional Procedures//If Yes, Specify Procedure
			7-Kidney Related Post-Operative Complications	Kidney Other Interventional Procedures Date//Date of Procedure
			8-Liver Related Post-Operative Complications	Lung Readmission Reason Other//Specify
			9-Lung Related Post-Operative Complications	Post-operative complications during the initial hospitalization
			9-Lung Related Post-Operative Complications	Post-operative Complications//If Yes, Specify
			9-Lung Related Post-Operative Complications	Arrhythmia requiring therapy
			9-Lung Related Post-Operative Complications	Placement of Additional Thoracostomy Tube(s), Indication
			9-Lung Related Post-Operative Complications	Post-operative Complications Other//Other Specify
			9-Lung Related Post-Operative Complications	Lung Readmission//Any Readmission After Initial Discharge
			9-Lung Related Post-Operative Complications	Lung Readmission Reason//If yes, specify reason for readmission (during first six weeks)
			8-Liver Related Post-Operative Complications	Lung Readmission Reason Other//Specify
			9-Lung Related Post-Operative Complications	Lung Readmission Date//If Yes, Date of First Readmission
			10-Post-Operative Clinical Information	Most Recent Date of Tests
			10-Post-Operative Clinical Information	Weight in Lb
			10-Post-Operative Clinical Information	Kidney Serum Creatinine
			10-Post-Operative Clinical Information	Kidney Serum Creatinine//Status
			10-Post-Operative Clinical Information	Post-Op Blood Pressure Systolic
			10-Post-Operative Clinical Information	Post-Op Blood Pressure Systolic//Status
			10-Post-Operative Clinical Information	Post-Op Blood Pressure Diastolic
			10-Post-Operative Clinical Information	Post-Op Blood Pressure Diastolic//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Urinalysis	Display Only
			10-Post-Operative Clinical Information	Post-Operative Urinalysis//Urine Protein	Value or status is reported, not both
			10-Post-Operative Clinical Information	Post-Operative Urinalysis//Protein-Creatinine Ratio
			10-Post-Operative Clinical Information	Donor Developed Hypertension Requiring Medication
			10-Post-Operative Clinical Information	Total Bilirubin	Value or status is reported, not both
			10-Post-Operative Clinical Information	Total Bilirubin//Status
			10-Post-Operative Clinical Information	SGOT/AST
			10-Post-Operative Clinical Information	SGOT/AST//Status
			10-Post-Operative Clinical Information	SGPT/ALT
			10-Post-Operative Clinical Information	SGPT/ALT//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Alkaline Phosphatase
			10-Post-Operative Clinical Information	Alkaline Phosphatase//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Serum Albumin
			10-Post-Operative Clinical Information	Serum Albumin//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Serum Creatinine
			10-Post-Operative Clinical Information	Serum Creatinine//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	INR
			10-Post-Operative Clinical Information	INR//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Post-Operative//Weight
			10-Post-Operative Clinical Information	Post-Operative Weight//Status	Value or status is reported, not both
			10-Post-Operative Clinical Information	Organ Recovery Date
			10-Post-Operative Clinical Information	Organ(s) Recovered	Value or status is reported, not both
			10-Post-Operative Clinical Information	Recipient Last Name
			10-Post-Operative Clinical Information	Recipient First Name	Value or status is reported, not both
			10-Post-Operative Clinical Information	Recipient SSN#
			10-Post-Operative Clinical Information	Donor Recovery Facility Center Code//Donor Recovery Facility	Display Only - Cascades from Database
			10-Post-Operative Clinical Information	Donor Recovery Facility Center Type	Display Only - Cascades from Database
			10-Post-Operative Clinical Information	Donor Workup Facility Center Code	Display Only - Cascades from Database
			10-Post-Operative Clinical Information	Donor Workup Facility Center Type	Display Only - Cascades from Database
			PUBLIC BURDEN STATEMENT:
			The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order to perform the following OPTN functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monitor compliance of member organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0157 and it is valid until XX/XX/20XX. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data collected will be subject to Privacy Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are well protected by a number of the Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed by OMB Circular A-130, Appendix III, Security of Federal Automated Information Systems, and the Departments Automated Information Systems Security Program Handbook. The public reporting burden for this collection of information is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].