2 Living Donor Registration_Form.xlsx

	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].