28 Liver Explant Pathology_clean.xlsx

Data System for Organ Procurement and Transplantation Network

Liver Explant Pathology_clean.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
Liver Recipient Explant Pathology Form






















Fields to be completed by members













































Form Section Field Label Notes






















Provider Information Transplant Center Code//Recipient Center Display Only - Cascades from TCR






















Provider Information Transplant Center Type//Recipient Center Display Only - Cascades from TCR






















Provider Information Transplant Center Display Only - Cascades from Database






















Recipient Information Recipient First Name//Name: Display Only - Cascades from TCR






















Recipient Information Recipient Last Name//Name: Display Only - Cascades from TCR






















Recipient Information Recipient Middle Initial//Name: Display Only - Cascades from TCR






















Recipient Information Tx Date Display Only - Cascades from Database






















Recipient Information Recipient SSN//SSN: Display Only - Cascades from TCR






















Recipient Information DOB Display Only - Cascades from Database






















Recipient Information Gender Display Only - Cascades from TCR






















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






















Clinical Information Number of Tumors






















Clinical Information Tumor #1//Size






















Clinical Information Tumor #1//Location






















Clinical Information Tumor #1//Tumor Necrosis






















Clinical Information Tumor #2//Size






















Clinical Information Tumor #2//Location






















Clinical Information Tumor #2//Tumor Necrosis






















Clinical Information Tumor #3//Size






















Clinical Information Tumor #3//Location






















Clinical Information Tumor #3//Tumor Necrosis






















Clinical Information Tumor #4//Size






















Clinical Information Tumor #4//Location






















Clinical Information Tumor #4//Tumor Necrosis






















Clinical Information Tumor #5//Size






















Clinical Information Tumor #5//Location






















Clinical Information Tumor #5//Tumor Necrosis






















Clinical Information Worst Tumor Differentiation






















Clinical Information Vascular Invasion






















Clinical Information Lymph Node Involvement






















Clinical Information Other Extrahepatic Spread






















Clinical Information Satellite Lesions






















Clinical Information Did recipient receive any pre-transplant liver-directed therapy 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/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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