55 Kidney Paired Donation Candidate Registration_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Kidney Paired Donation Candidate Registration_Form.xlsx

OMB: 0915-0157

Document [xlsx]
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Kidney Paired Donation Candidate Registration



Fields to be completed by members







Form Section Field Label Notes



Add a KPD Candidate Institution: Home transplant center



Add a KPD Candidate SSN



Add a KPD Candidate Date of birth



Add a KPD Candidate Waitlist ID



Candidate Summary Details Institution Home transplant center This field cannot be updated on this page



Candidate Summary Details Demographic Information Last name This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information First name This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information Middle initial This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information SSN This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information Date of birth This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information Current age This field cannot be updated on this page



Candidate Summary Details Demographic Information Gender This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information Center's patient ID This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information State of permanent residence This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information Permanent zip code This field is copied from the candidate’s Waitlist registration



Candidate Summary Details Demographic Information Ethnicity/race



Candidate Details Clinical Information ABO If the KPD candidate has an existing record in Waitlist, the KPD candidate's ABO blood type is copied from Waitlist



Candidate Details Clinical Information Height If the KPD candidate has an existing record in Waitlist, the KPD candidate's height is copied from Waitlist



Candidate Details Clinical Information Weight If the KPD candidate has an existing record in Waitlist, the KPD candidate's weight is copied from Waitlist



Candidate Details Clinical Information BMI This field cannot be updated



Candidate Details Clinical Information CPRA The KPD candidate's CPRA displays based on information entered in Waitlist. This field cannot be updated



Candidate Details Clinical Information Is candidate currently on dialysis? The answer to this question displays based on information entered in Waitlist. This field cannot be updated



Candidate Details Clinical Information Dialysis date The answer to this question displays based on information entered in Waitlist. This field cannot be updated



Candidate Details KPD Information Has the candidate signed the Agreement to participate in the KPD Pilot Program?



Candidate Details KPD Information Has the candidate signed to release protected health information so that medical information may be shared with other transplant hospitals?



Candidate Details KPD Information Is the candidate a prior living donor?



Candidate Details KPD Information KPD waiting time start date



Candidate Details KPD Information Is the candidate considered a pediatric candidate in the KPD system? This field cannot be updated on this page



Candidate Details KPD Information Orphaned candidate This field cannot be updated



Candidate Details KPD Information KPD status



Candidate Details KPD Information Inactive reason



Candidate Details KPD Information Other, Specify



Candidate Details KPD Information Removal reason



Candidate Details KPD Information Other, Specify



Candidate Details Comments Comments



Candidate Choices Institution Home transplant center This field cannot be updated on this page



Candidate Choices KPD Candidate Choices Candidate willing to travel?



Candidate Choices KPD Candidate Choices If so, to which center(s) is the candidate willing to travel?



Candidate Choices KPD Candidate Choices Would candidate be willing to travel further if funding were provided?



Candidate Choices KPD Candidate Choices Will candidate accept a shipped kidney?



Candidate Choices KPD Candidate Choices If yes, from which centers is the candidate willing to accept a shipped kidney?



Candidate Choices KPD Candidate Choices Minimum acceptable donor age



Candidate Choices KPD Candidate Choices Maximum acceptable donor age



Candidate Choices KPD Candidate Choices Minimum acceptable donor BMI



Candidate Choices KPD Candidate Choices Minimum acceptable donor creatinine clearance (24-hour urine collection) or donor GFR (isotopic method)



Candidate Choices KPD Candidate Choices Maximum acceptable donor blood pressure – systolic (average)



Candidate Choices KPD Candidate Choices Maximum acceptable donor blood pressure - diastolic (average)



Candidate Choices KPD Candidate Choices Candidate willing to accept a donor who is Hep B core antibody positive?* *Assumes donor is Hep B surface antigen negative



Candidate Choices KPD Candidate Choices Candidate willing to accept a CMV positive donor?



Candidate Choices KPD Candidate Choices Candidate willing to accept an EBV positive donor?



Candidate Choices KPD Candidate Choices Candidate willing to accept only left kidney, only right kidney, or either kidney?



HLA and Unacceptables Institution Home transplant center This field cannot be updated on this page



HLA and Unacceptables Class I A



HLA and Unacceptables Class I B



HLA and Unacceptables Class I BW4



HLA and Unacceptables Class I BW6



HLA and Unacceptables Class I C



HLA and Unacceptables Class II DR



HLA and Unacceptables Class II DR51



HLA and Unacceptables Class II DR52



HLA and Unacceptables Class II DR53



HLA and Unacceptables Class II DQB1



HLA and Unacceptables Class II DQA1



HLA and Unacceptables Class II DPB1



HLA and Unacceptables Testing and Review of Unacceptables Tested for anti HLA antibodies



HLA and Unacceptables Testing and Review of Unacceptables If yes, most recent antibody test date



HLA and Unacceptables Testing and Review of Unacceptables Prior to a candidate appearing on their first match run, all unacceptable antigens in KPD must be reviewed. Have all the candidate’s unacceptable antigens been reviewed?



HLA and Unacceptables Unacceptable Antigens CPRA value used for allocation per OPTN policy This field cannot be updated on this screen



HLA and Unacceptables Unacceptable Antigens Detailed CPRA value This field cannot be updated on this screen



HLA and Unacceptables Unacceptable Antigens Select all A unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all B unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select BW unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all C unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all DR unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all DR 51 unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all DR 52 unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all DR 53 unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all DQB1 unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all DQA1 unacceptable antigens



HLA and Unacceptables Unacceptable Antigens Select all DPB1 unacceptable antigens



HLA and Unacceptables All Other Antibody Specificities Select all A other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select all B other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select BW other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select all C other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select all DR other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select all DR 51 other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select all DR 52 unacceptable antigens



HLA and Unacceptables All Other Antibody Specificities Select all DR 53 unacceptable antigens



HLA and Unacceptables All Other Antibody Specificities Select all DQB1 other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select all DQA1 other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select all DPB1 other antibody specificities



HLA and Unacceptables All Other Antibody Specificities Select all DPB1 other epitope specificities



Titers Institution Home transplant center



Titers-Titer Information If the candidate is B, is the candidate willing to accept an A2 or A2B donor? This question only displays if the candidate has an ABO blood type of B



Titers-Titer Information If the candidate is willing to accept an A2 donor or A2B donor, enter IgG antibody titer



Titers-Titer Information Titer



Titers-Titer Information Date



Titers-Titer Information Candidate current eligibility status for A2 and A2B donor This is a read-only field



Titers-Titer Information If the candidate is O, is the candidate willing to accept an A2 donor? This question only displays if the candidate has an ABO blood type of O



Titers-Titer Information If the candidate is willing to accept an A2 donor, enter anti-A titer



Titers-Titer Information Titer



Titers-Titer Information Date



Titers-Titer Information Candidate current eligibility status for A2 donor This is a read-only field



Verify Candidate ABO Candidate Information Last name This field is read-only



Verify Candidate ABO Candidate Information First name This field is read-only



Verify Candidate ABO Candidate Information Middle initial This field is read-only



Verify Candidate ABO Candidate Information ABO



Verify Candidate ABO Candidate Information Age This field is read-only



Verify Candidate ABO Candidate Information Gender This field is read-only



Verify Candidate ABO Candidate Information First user ABO entry This field is read-only



Donor Pre-Screen Candidate Information KPD Candidate ID Unique numeric ID generated by system. This field is read-only



Donor Pre-Screen Candidate Information Candidate name This field is read-only



Donor Pre-Screen Candidate Information Candidate HLA This field is read-only



Donor Pre-Screen Candidate Information Candidate CPRA This field is read-only



Donor Pre-Screen Candidate Information Candidate unacceptable antigens This field is read-only



Donor Pre-Screen Candidate Information All other antibody specificities This field is read-only



Donor Pre-Screen Candidate Information Candidate ABO This field is read-only



Potential donors available for pre-screening KPD Donor ID This field is read-only



Potential donors available for pre-screening Donor HLA This field is read-only



Potential donors available for pre-screening BMI/Height/Weight This field is read-only



Potential donors available for pre-screening Creatinine Clearance (ml/min) This field is read-only



Potential donors available for pre-screening GFR (isotopic method) (ml/min/1.73 m2) This field is read-only



Potential donors available for pre-screening Age This field is read-only



Potential donors available for pre-screening M/F This field is read-only



Potential donors available for pre-screening ABO This field is read-only



Potential donors available for pre-screening Kidney choice This field is read-only



Potential donors available for pre-screening Left kidney arteries This field is read-only



Potential donors available for pre-screening Left kidney veins This field is read-only



Potential donors available for pre-screening Left kidney ureter This field is read-only



Potential donors available for pre-screening Right kidney arteries This field is read-only



Potential donors available for pre-screening Right kidney veins This field is read-only



Potential donors available for pre-screening Right kidney ureter This field is read-only



Potential donors available for pre-screening Pre-accept/Pre-refuse



Potential donors available for pre-screening Pre-screen last updated



Potential donors available for pre-screening Donor last updated This field is read-only



Donor Pre-Screen Donors pre-refused KPD Donor ID This field is read-only



Donor Pre-Screen Donors pre-refused Donor HLA This field is read-only



Donor Pre-Screen Donors pre-refused BMI/Height/Weight This field is read-only



Donor Pre-Screen Donors pre-refused Creatinine clearance (ml/min) This field is read-only



Donor Pre-Screen Donors pre-refused GFR (isotopic method) (ml/min/1.73 m2) This field is read-only



Donor Pre-Screen Donors pre-refused Age This field is read-only



Donor Pre-Screen Donors pre-refused M/F This field is read-only



Donor Pre-Screen Donors pre-refused ABO This field is read-only



Donor Pre-Screen Donors pre-refused Kidney choice This field is read-only



Donor Pre-Screen Donors pre-refused Left kidney arteries This field is read-only



Donor Pre-Screen Donors pre-refused Left kidney veins This field is read-only



Donor Pre-Screen Donors pre-refused Left kidney ureter This field is read-only



Donor Pre-Screen Donors pre-refused Right kidney arteries This field is read-only



Donor Pre-Screen Donors pre-refused Right kidney veins This field is read-only



Donor Pre-Screen Donors pre-refused Right kidney ureter This field is read-only



Donor Pre-Screen Donors pre-refused Pre-accept/Pre-refuse



Donor Pre-Screen Donors pre-refused Pre-screen last updated This field is read-only



Donor Pre-Screen Donors pre-refused Donor last updated This field is read-only



Donor Pre-Screen-Donors pre-accepted KPD Donor ID This field is read-only



Donor Pre-Screen-Donors pre-accepted Donor HLA This field is read-only



Donor Pre-Screen-Donors pre-accepted BMI/Height/Weight This field is read-only



Donor Pre-Screen-Donors pre-accepted Creatinine Clearance (ml/min) This field is read-only



Donor Pre-Screen-Donors pre-accepted GFR (isotopic method) (ml/min/1.73 m2) This field is read-only



Donor Pre-Screen-Donors pre-accepted Age This field is read-only



Donor Pre-Screen-Donors pre-accepted M/F This field is read-only



Donor Pre-Screen-Donors pre-accepted ABO This field is read-only



Donor Pre-Screen-Donors pre-accepted Kidney choice This field is read-only



Donor Pre-Screen-Donors pre-accepted Left kidney arteries This field is read-only



Donor Pre-Screen-Donors pre-accepted Left kidney veins This field is read-only



Donor Pre-Screen-Donors pre-accepted Left kidney ureter This field is read-only



Donor Pre-Screen-Donors pre-accepted Right kidney arteries This field is read-only



Donor Pre-Screen-Donors pre-accepted Right kidney veins This field is read-only



Donor Pre-Screen-Donors pre-accepted Right kidney ureter This field is read-only



Donor Pre-Screen-Donors pre-accepted Pre-accept/Pre-refuse



Donor Pre-Screen-Donors pre-accepted Pre-screen last updated This field is read-only



Donor Pre-Screen-Donors pre-accepted Donor last updated This field is read-only





















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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