Form 4 Donor Histocompatibility_Form.xlsx

			Donor Histocompatibility (DHS)
			Fields to be completed by members
			Form Section	Field Label	Notes
			1-Provider Information	Lab Center Code	Display Only - Cascades from Database
			1-Provider Information	Lab Center Type	Display Only - Cascades from Database
			1-Provider Information	OPO Center Code	Display Only - Cascades from Database
			1-Provider Information	OPO Center Type	Display Only - Cascades from Database
			2-Donor Information	UNOS Donor ID//UNOS Donor ID #	Display Only - Cascades from feedback
			2-Donor Information	Donor Type	Display Only - Cascades from feedback
			3-Donor Typing	Donor HLA Typed
			3-Donor Typing	Date Typing Complete Class I
			3-Donor Typing	Target Source for Class I
			4-Typing Method Class I	Typing Method Class I
			4-Typing Method Class I	A
			4-Typing Method Class I	A
			4-Typing Method Class I	B
			4-Typing Method Class I	B
			4-Typing Method Class I	Bw4
			4-Typing Method Class I	Bw6
			4-Typing Method Class I	Cw
			4-Typing Method Class I	Cw
			3-Donor Typing	Date Typing Complete Class II
			3-Donor Typing	Target Source for Class II
			4-Typing Method Class II	Typing Method Class II
			5-Typing Method Class II	DR
			5-Typing Method Class II	DR
			5-Typing Method Class II	DR51
			5-Typing Method Class II	DR52
			5-Typing Method Class II	DR53
			5-Typing Method Class II	DQB
			5-Typing Method Class II	DQB
			5-Typing Method Class II	DQA
			5-Typing Method Class II	DQA
			5-Typing Method Class II	DPB
			5-Typing Method Class II	DPB
			5-Typing Method Class II	DPA
			5-Typing Method Class II	DPA
			4-Living Donor Information	Living Recipient Last Name	Display Only - Cascades from Database
			4-Living Donor Information	Living Recipient First Name	Display Only - Cascades from Database
			6-Living Donor Information/File Layout	SSN	Display Only - Cascades from Database
			6-Living Donor Information	Organ	Display Only - Cascades from Database
			6-Living Donor Information	Transplant Date	Display Only - Cascades from Database
			6-Living Donor Information	Transplant Center	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].