53 Organ Labeling and Packaging_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Organ Labeling and Packaging_Form.xlsx

OMB: 0915-0157

Document [xlsx]
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Organ Labeling and Packaging



Fields to be completed by members







Form Section Field Label Notes



Donor Setup-Donor Hospital Hospital Name



Donor Setup-Donor Hospital City



Donor Setup-Donor Hospital State



Donor Setup-Donor Hospital Zip



Donor Setup-Donor Hospital Time Zone



Donor Setup-Donor Hospital DST Observed



Donor Setup-Donor Info Donor ID



Donor Setup-Donor Info ABO



Donor Setup-Donor Info Date of Birth



Donor Setup-Donor Info Donor Initials



Donor Setup-Donor Info Local ID



Donor Setup-Donor Info Verified Donor ID



Donor Setup-Donor Info Verified ABO



Donor Setup-Donor Info Verified Date of Birth



Donor Setup-Donor Info Verified Donor Initials



Donor Setup-Donor Info Verified Local ID



Blood & Culture Labels-Blood Tubes With ABO Draw Date



Blood & Culture Labels-Blood Tubes With ABO Draw Time



Blood & Culture Labels-Blood Tubes With ABO Initials



Blood & Culture Labels-Blood Tubes With ABO Comments



Blood & Culture Labels-Blood Tubes Without ABO Draw Date



Blood & Culture Labels-Blood Tubes Without ABO Draw Time



Blood & Culture Labels-Blood Tubes Without ABO Initials



Blood & Culture Labels-Blood Tubes Without ABO Comments



Blood & Culture Labels-Cultures Draw Date



Blood & Culture Labels-Cultures Draw Time



Blood & Culture Labels-Cultures Initials



Blood & Culture Labels-Cultures Type



Blood & Culture Labels-Cultures Site



Infectious Disease Results Anti-HBc



Infectious Disease Results Anti-HIV I/II



Infectious Disease Results HIV Ag/Ab Combo



Infectious Disease Results HIV NAT



Infectious Disease Results HBsAg



Infectious Disease Results HBV NAT



Infectious Disease Results Anti-HCV



Infectious Disease Results HCV NAT



Infectious Disease Results PHS Increased Risk Donor?



Infectious Disease Results Verified Anti-HBc



Infectious Disease Results Verified Anti-HIV I/II



Infectious Disease Results Verified HIV Ag/Ab Combo



Infectious Disease Results Verified HIV NAT



Infectious Disease Results Verified HBsAg



Infectious Disease Results Verified HBV NAT



Infectious Disease Results Verified Anti-HCV



Infectious Disease Results Verified HCV NAT



Infectious Disease Results Verified PHS Increased Risk Donor?



Procurement Plan Heart



Procurement Plan Left Lung



Procurement Plan Right Lung



Procurement Plan Lungs Enbloc



Procurement Plan Liver



Procurement Plan Liver Split Left



Procurement Plan Liver Split Right



Procurement Plan Pancreas



Procurement Plan Left Kidney



Procurement Plan Right Kidney



Procurement Plan Kidneys Enbloc



Procurement Plan Intestine



Procurement Date



Procurement Time



Procurement – Organ Detail Ice Date



Procurement – Organ Detail Ice Time



Procurement – Organ Detail Initials



Procurement – Organ Detail Ice Date 2



Procurement – Organ Detail Ice Time 2



Procurement – Organ Detail Initials 2



Tissue/Extra Vessel Labels Ice Date



Tissue/Extra Vessel Labels Ice Time



Tissue/Extra Vessel Labels Initials



Tissue/Extra Vessel Labels Ice Date 2



Tissue/Extra Vessel Labels Ice Time 2



Tissue/Extra Vessel Labels Initials 2



VCA Packaging Excision Date (Right)



VCA Packaging Excision Time (Right)



VCA Packaging Excision Date (Left)



VCA Packaging Excision Time (Left)



VCA Packaging Ice Date



VCA Packaging Ice Time



VCA Packaging Initials



VCA Packaging Ice Date 2



VCA Packaging Ice Time 2



VCA Packaging Initials 2





















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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