28 Liver Recipient Explant Pathology_Form.xlsx

Fields to be completed by members

Form Section

Field Label

Notes

1- Provider Information

Transplant Center Code//Recipient Center

Display Only - Cascades from TCR

1- Provider Information

Transplant Center Type//Recipient Center

Display Only - Cascades from TCR

1- Provider Information

Transplant Center

Display Only - Cascades from Database

2- Recipient Information

Recipient First Name//Name:

Display Only - Cascades from TCR

2- Recipient Information

Recipient Last Name//Name:

Display Only - Cascades from TCR

2- Recipient Information

Recipient Middle Initial//Name:

Display Only - Cascades from TCR

2- Recipient Information

Tx Date

Display Only - Cascades from Database

2- Recipient Information

Recipient SSN//SSN:

Display Only - Cascades from TCR

2- Recipient Information

DOB

Display Only - Cascades from Database

2- Recipient Information

Gender

Display Only - Cascades from TCR

3- Clinical Information

Was evidence of HCC (viable or non-viable tumor) found in the explant?

3- Clinical Information

Number of Tumors

3- Clinical Information

Tumor #1//Size

3- Clinical Information

Tumor #1//Location

3- Clinical Information

Tumor #1//Tumor Necrosis

3- Clinical Information

Tumor #2//Size

3- Clinical Information

Tumor #2//Location

3- Clinical Information

Tumor #2//Tumor Necrosis

3- Clinical Information

Tumor #3//Size

3- Clinical Information

Tumor #3//Location

3- Clinical Information

Tumor #3//Tumor Necrosis

3- Clinical Information

Tumor #4//Size

3- Clinical Information

Tumor #4//Location

3- Clinical Information

Tumor #4//Tumor Necrosis

3- Clinical Information

Tumor #5//Size

3- Clinical Information

Tumor #5//Location

3- Clinical Information

Tumor #5//Tumor Necrosis

3- Clinical Information

Worst Tumor Differentiation

3- Clinical Information

Vascular Invasion

3- Clinical Information

Lymph Node Involvement

3- Clinical Information

Other Extrahepatic Spread

3- Clinical Information

Satellite Lesions

3- Clinical Information

Pre-transplant treatment for HCC?

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].