2 Living Donor Registration_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Living Donor Registration_Form.xlsx

OMB: 0915-0157

Document [xlsx]
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Living Donor Registration (LDR)

Fields to be completed by members







Form Section Field Label Notes

Provider Information Recipient Center Name Display Only

Provider Information Center Code Type Display Only - Cascades from Database

Provider Information Center Code Display Only - Cascades from Database

Donor Information Donor Last Name Display Only - Cascades from Database

Donor Information Donor First Name Display Only - Cascades from Database

Donor Information UNOS Donor ID # Display Only - Cascades from feedback

Donor Information Home Address

Donor Information Home City

Donor Information Home State

Donor Information Home Zip

Donor Information Home Phone

Donor Information Work Phone Not required

Donor Information Email Not required

Donor Information Donor SSN

Donor Information Donor Date of Birth

Donor Information Donor Gender//Gender

Donor Information Marital Status at Time of Donation

Donor Information ABO Blood Group Display Only - Cascades from Database

Donor Information Living Donor Type

Donor Information Living Donor Type Other Specify

Donor Information Ethnicity/Race

Donor Information Citizenship

Donor Information Year of Entry into U.S.

Donor Information Country of Permanent Residence

Donor Information Highest Education Level

Donor Information Did the donor have health insurance

Donor Information Functional Status

Donor Information Physical Capacity: (check one)

Donor Information Working for Income

Donor Information Working for Income//If No, Not Working Due To: (check one)

Donor Information Working for Income//If Yes

Donor Information % Macro vesicular fat

Donor Information % Micro vesicular fat

Pre-Donation Clinical Information Viral Detection://Have any of the following viruses ever been tested for: HIV, CMV, HBV, HCV, EBV

Pre-Donation Clinical Information HIV Status

Pre-Donation Clinical Information CMV Total Not required

Pre-Donation Clinical Information CMV//IgG

Pre-Donation Clinical Information CMV//IgM

Pre-Donation Clinical Information CMV//Nucleic Acid Testing Not required

Pre-Donation Clinical Information HBV

Pre-Donation Clinical Information HBV//Core Antibody

Pre-Donation Clinical Information HBV//Surface Antigen

Pre-Donation Clinical Information HBV//HBV/DNA (NAT/PCR)

Pre-Donation Clinical Information HCV

Pre-Donation Clinical Information HCV//Antibody

Pre-Donation Clinical Information HCV//RIBA

Pre-Donation Clinical Information HCV//HCV/RNA (NAT/PCR)

Pre-Donation Clinical Information EBV Total

Pre-Donation Clinical Information EBV//IgG

Pre-Donation Clinical Information EBV//IgM

Pre-Donation Clinical Information Pre-Donation//Height

Pre-Donation Clinical Information Pre-Donation Height//Status

Pre-Donation Clinical Information Pre-Donation//Weight

Pre-Donation Clinical Information Pre-Donation Weight//Status

Pre-Donation Clinical Information History of Cancer

Pre-Donation Clinical Information History of Cancer Specify//Specify Value or status is reported, not both

Pre-Donation Clinical Information Cancer Free Interval

Pre-Donation Clinical Information Cancer Free Interval //Status Value or status is reported, not both

Pre-Donation Clinical Information History of Cigarette Use

Pre-Donation Clinical Information History of Cigarette Use Pack Years//If Yes, Check # pack years

Pre-Donation Clinical Information Duration of Abstinence

Pre-Donation Clinical Information Other Tobacco Used Value or status is reported, not both

Pre-Donation Liver Clinical Information Total Bilirubin

Pre-Donation Liver Clinical Information Total Bilirubin//Status

Pre-Donation Liver Clinical Information SGOT/AST

Pre-Donation Liver Clinical Information SGOT/AST//Status

Pre-Donation Liver Clinical Information SGPT/ALT

Pre-Donation Liver Clinical Information SGPT/ALT//Status Value or status is reported, not both

Pre-Donation Liver Clinical Information Alkaline Phosphatase

Pre-Donation Liver Clinical Information Alkaline Phosphatase//Status Value or status is reported, not both

Pre-Donation Liver Clinical Information Serum Albumin

Pre-Donation Liver Clinical Information Serum Albumin//Status Value or status is reported, not both

Pre-Donation Liver Clinical Information Serum Creatinine

Pre-Donation Liver Clinical Information Serum Creatinine//Status Value or status is reported, not both

Pre-Donation Liver Clinical Information INR

Pre-Donation Liver Clinical Information INR//Status Value or status is reported, not both

Pre-Donation Liver Clinical Information Liver Biopsy

Pre-Donation Liver Clinical Information % Macro/intermediate vesicular fat //Status Value or status is reported, not both

Pre-Donation Liver Clinical Information % Micro/intermediate vesicular fat //Status

Pre-Donation Kidney Clinical Information History of Hypertension

Pre-Donation Kidney Clinical Information History of Hypertension Diet

Pre-Donation Kidney Clinical Information History of Hypertension Diuretics Display Only - Cascades from Database

Pre-Donation Kidney Clinical Information History of Hypertension Other Hypertensive Medication

Pre-Donation Kidney Clinical Information Diabetes

Pre-Donation Kidney Clinical Information Diabetes Treatment

Pre-Donation Kidney Clinical Information Kidney Preoperative Creatinine//Serum Creatinine

Pre-Donation Kidney Clinical Information Kidney Preoperative Creatinine//Status

Pre-Donation Kidney Clinical Information Preoperative Blood Pressure Systolic

Pre-Donation Kidney Clinical Information Preoperative Blood Pressure Systolic//Status

Pre-Donation Kidney Clinical Information Preoperative Blood Pressure Diastolic

Pre-Donation Kidney Clinical Information Preoperative Blood Pressure Diastolic//Status Value or status is reported, not both

Pre-Donation Kidney Clinical Information Urinalysis Display Only

Pre-Donation Kidney Clinical Information Preoperative Urinalysis//Urine Protein Value or status is reported, not both

Pre-Donation Kidney Clinical Information Preoperative Urinalysis//Protein-Creatinine Ratio

Pre-Donation Lung Clinical Information Diabetes

Pre-Donation Lung Clinical Information Diabetes Treatment

Pre-Donation Lung Clinical Information FVC % predicted before//FVC % predicted Value or status is reported, not both

Pre-Donation Lung Clinical Information FVC % predicted before//Status

Pre-Donation Lung Clinical Information FVC % predicted after//FVC % predicted Value or status is reported, not both

Pre-Donation Lung Clinical Information FVC % predicted after//Status Value or status is reported, not both

Pre-Donation Lung Clinical Information FEV1 % predicted before//FEV1 % predicted

Pre-Donation Lung Clinical Information FEV1 % predicted before//Status Value or status is reported, not both

Pre-Donation Lung Clinical Information FEV1 % predicted after//FEV1 % predicted

Pre-Donation Lung Clinical Information FEV1 % predicted after//Status Value or status is reported, not both

Pre-Donation Lung Clinical Information FEF (25-75%) % predicted before//FEF (25-75%) % predicted

Pre-Donation Lung Clinical Information FEF (25-75%) % predicted before//Status Value or status is reported, not both

Pre-Donation Lung Clinical Information FEF (25-75%) % predicted after//FEF (25-75%) % predicted

Pre-Donation Lung Clinical Information FEF (25-75%) % predicted after//Status Value or status is reported, not both

Pre-Donation Lung Clinical Information TLC % predicted before//TLC % predicted

Pre-Donation Lung Clinical Information TLC % predicted before//Status Value or status is reported, not both

Pre-Donation Lung Clinical Information TLC % predicted after//TLC % predicted

Pre-Donation Lung Clinical Information TLC % predicted after//Status Value or status is reported, not both

Pre-Donation Lung Clinical Information Diffusing lung capacity corrected for alveolar volume % predicted

Pre-Donation Lung Clinical Information Diffusing lung capacity corrected for alveolar volume % predicted//Status Value or status is reported, not both

Pre-Donation Lung Clinical Information PaO2 on room air

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

Post-Operative Information Date of Initial Discharge

Post-Operative Information Donor Status

Post-Operative Information Date Last Seen or Death

Post-Operative Information Cause of Death

Post-Operative Information Cause of Death//Other Specify

Post-Operative Information Non-Autologous Blood Administration

Post-Operative Information PRBC Units//If Yes, Number of Units

Post-Operative Information Platelets Units//If Yes, Number of Units

Post-Operative Information FF Units//If Yes, Number of Units

Liver Related Post-Operative Complications Biliary Complications

Liver Related Post-Operative Complications Biliary Complications//If Yes, Specify

Liver Related Post-Operative Complications Biliary Complications//If Yes, Specify://Date of surgery

Liver Related Post-Operative Complications Liver Vascular Complications Requiring Intervention//Vascular Complications Requiring Intervention

Liver Related Post-Operative Complications Liver Vascular Complications//If Yes, Specify

Liver Related Post-Operative Complications Liver Vascular Complications Other//Specify

Liver Related Post-Operative Complications Liver Other Complications Requiring Intervention

Liver Related Post-Operative Complications Liver Other Complications//If Yes, Specify

Liver Related Post-Operative Complications Liver Other Complications Other//Specify

Liver Related Post-Operative Complications Liver Reoperation

Liver Related Post-Operative Complications Reoperation//If yes, specify reason for reoperation (during first six weeks)

Liver Related Post-Operative Complications Liver Reoperation Liver Failure

Liver Related Post-Operative Complications Liver Reoperation Liver Failure Date

Liver Related Post-Operative Complications Liver Reoperation Bleeding Complications

Liver Related Post-Operative Complications Liver Reoperation Bleeding Date//Date

Liver Related Post-Operative Complications Liver Reoperation Hernia Repair

Liver Related Post-Operative Complications Liver Reoperation Hernia Repair Date

Liver Related Post-Operative Complications Liver Reoperation Bowel Obstruction

Liver Related Post-Operative Complications Liver Reoperation Bowel Obstruction Date

Liver Related Post-Operative Complications Liver Reoperation Vascular Complications

Liver Related Post-Operative Complications Liver Reoperation Vascular Date

Liver Related Post-Operative Complications Liver Reoperation Other//Other Specify

Liver Related Post-Operative Complications Liver Reoperation Other Specify//Other Specify

Liver Related Post-Operative Complications Liver Reoperation Other Date

Liver Related Post-Operative Complications Liver Readmission//Any Readmission After Initial Discharge

Liver Related Post-Operative Complications Liver Readmission Reason//If yes, specify reason for readmission (during first six weeks)

Liver Related Post-Operative Complications Liver Readmission Reason Other//Other Specify

Liver Related Post-Operative Complications Liver Readmission Date//If Yes, Date of First Readmission

Liver Related Post-Operative Complications Liver Other Interventional Procedures

Liver Related Post-Operative Complications Liver Other Interventional Procedures//If Yes, Specify Procedure

Liver Related Post-Operative Complications Liver Other Interventional Procedures Date//Date of Procedure

Kidney Related Post-Operative Complications Kidney Vascular Complications Requiring Intervention//Vascular Complications Requiring Intervention

Kidney Related Post-Operative Complications Kidney Vascular Complications//If Yes, Specify

Kidney Related Post-Operative Complications Kidney Vascular Complications Other//Specify

Kidney Related Post-Operative Complications Kidney Other Complications Requiring Intervention//Other Complications Requiring Intervention

Kidney Related Post-Operative Complications Kidney Other Complications//If Yes, Specify

Kidney Related Post-Operative Complications Kidney Other Complications Other//Other Specify

Kidney Related Post-Operative Complications Kidney Reoperation//Reoperation

Kidney Related Post-Operative Complications Reoperation//If yes, specify reason for reoperation (during first six weeks)

Kidney Related Post-Operative Complications Kidney Reoperation Bleeding//Bleeding

Kidney Related Post-Operative Complications Kidney Reoperation Bleeding Date//Date

Kidney Related Post-Operative Complications Kidney Reoperation Hernia Repair//Hernia Repair

Kidney Related Post-Operative Complications Kidney Reoperation Hernia Repair Date//Date

Kidney Related Post-Operative Complications Kidney Reoperation Bowel Obstruction//Bowel Obstruction

Kidney Related Post-Operative Complications Kidney Reoperation Bowel Obstruction Date//Date

Kidney Related Post-Operative Complications Kidney Reoperation Vascular//Vascular

Kidney Related Post-Operative Complications Kidney Reoperation Vascular Date//Date

Kidney Related Post-Operative Complications Kidney Reoperation Other//Other Specify

Kidney Related Post-Operative Complications Kidney Reoperation Other Specify//Other Specify

Kidney Related Post-Operative Complications Kidney Reoperation Other Date//Date

Kidney Related Post-Operative Complications Kidney Readmission//Any Readmission After Initial Discharge

Kidney Related Post-Operative Complications Kidney Readmission Reason//If yes, specify reason for readmission (during first six weeks)

Kidney Related Post-Operative Complications Kidney Readmission Reason Other//Other Specify

Kidney Related Post-Operative Complications Kidney Readmission Date//If Yes, Date of First Readmission

Kidney Related Post-Operative Complications Kidney Other Interventional Procedures//Other Interventional Procedures

Kidney Related Post-Operative Complications Kidney Other Interventional Procedures//If Yes, Specify Procedure

Kidney Related Post-Operative Complications Kidney Other Interventional Procedures Date//Date of Procedure

Liver Related Post-Operative Complications Lung Readmission Reason Other//Specify

Liver Related Post-Operative Complications Post-operative complications during the initial hospitalization

Liver Related Post-Operative Complications Post-operative Complications//If Yes, Specify

Liver Related Post-Operative Complications Arrhythmia requiring therapy

Liver Related Post-Operative Complications Placement of Additional Thoracostomy Tube(s), Indication

Liver Related Post-Operative Complications Post-operative Complications Other//Other Specify

Liver Related Post-Operative Complications Lung Readmission//Any Readmission After Initial Discharge

Lung Related Post-Operative Complications Lung Readmission Reason//If yes, specify reason for readmission (during first six weeks)

Liver Related Post-Operative Complications Lung Readmission Reason Other//Specify

Lung Related Post-Operative Complications Lung Readmission Date//If Yes, Date of First Readmission

Post-Operative Clinical Information Most Recent Date of Tests

Post-Operative Clinical Information Weight in lb.

Post-Operative Clinical Information Kidney Serum Creatinine

Post-Operative Clinical Information Kidney Serum Creatinine//Status

Post-Operative Clinical Information Post-Op Blood Pressure Systolic

Post-Operative Clinical Information Post-Op Blood Pressure Systolic//Status

Post-Operative Clinical Information Post-Op Blood Pressure Diastolic

Post-Operative Clinical Information Post-Op Blood Pressure Diastolic//Status Value or status is reported, not both

Post-Operative Clinical Information Urinalysis Display Only

Post-Operative Clinical Information Post-Operative Urinalysis//Urine Protein Value or status is reported, not both

Post-Operative Clinical Information Post-Operative Urinalysis//Protein-Creatinine Ratio

Post-Operative Clinical Information Donor Developed Hypertension Requiring Medication

Post-Operative Clinical Information Total Bilirubin Value or status is reported, not both

Post-Operative Clinical Information Total Bilirubin//Status

Post-Operative Clinical Information SGOT/AST

Post-Operative Clinical Information SGOT/AST//Status

Post-Operative Clinical Information SGPT/ALT

Post-Operative Clinical Information SGPT/ALT//Status Value or status is reported, not both

Post-Operative Clinical Information Alkaline Phosphatase

Post-Operative Clinical Information Alkaline Phosphatase//Status Value or status is reported, not both

Post-Operative Clinical Information Serum Albumin

Post-Operative Clinical Information Serum Albumin//Status Value or status is reported, not both

Post-Operative Clinical Information Serum Creatinine

Post-Operative Clinical Information Serum Creatinine//Status Value or status is reported, not both

Post-Operative Clinical Information INR

Post-Operative Clinical Information INR//Status Value or status is reported, not both

Post-Operative Clinical Information Post-Operative//Weight

Post-Operative Clinical Information Post-Operative Weight//Status Value or status is reported, not both

Post-Operative Clinical Information Organ Recovery Date

Post-Operative Clinical Information Organ(s) Recovered Value or status is reported, not both

Post-Operative Clinical Information Recipient Last Name

Post-Operative Clinical Information Recipient First Name Value or status is reported, not both

Post-Operative Clinical Information Recipient SSN#

Post-Operative Clinical Information Donor Recovery Facility Center Code//Donor Recovery Facility Display Only - Cascades from Database

Post-Operative Clinical Information Donor Recovery Facility Center Type Display Only - Cascades from Database

Post-Operative Clinical Information Donor Workup Facility Center Code Display Only - Cascades from Database

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/202X. 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 0.7 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].














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