56 Kidney Paired Donation Donor Registration_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Kidney Paired Donation Donor Registration_Form.xlsx

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf



Kidney Paired Donation Donor Registration



Fields to be completed by members







Form Section Field Label Notes



Add a KPD Donor-Institution Home transplant center



Add a KPD Donor Is this a non-directed donor?



Add a KPD Donor KPD candidate ID



Add a KPD Donor Donor name



Add a KPD Donor SSN



Add a KPD Donor Date of birth



Add a KPD Donor Donor status



Add KPD Donor (Non-directed) Home transplant center



Add KPD Donor (Non-directed) Is this a non-directed donor



Add KPD Donor (Non-directed) Donor name



Add KPD Donor (Non-directed) SSN



Add KPD Donor (Non-directed) Date of birth



Add KPD Donor (Non-directed) Donor status



Donor Summary Details-Institution Home transplant center This field cannot be updated on this page.



Donor Summary Details-Demographic Information Last name



Donor Summary Details-Demographic Information First name



Donor Summary Details-Demographic Information Middle initial



Donor Summary Details-Demographic Information SSN



Donor Summary Details-Demographic Information Date of birth



Donor Summary Details-Demographic Information Current age



Donor Summary Details-Demographic Information Gender



Donor Summary Details-Demographic Information Center's patient ID



Donor Summary Details-Demographic Information State of permanent residence



Donor Summary Details-Demographic Information Permanent zip code



Donor Summary Details-Demographic Information Ethnicity/race



Donor Summary Details-Clinical Information ABO



Donor Summary Details-Clinical Information Height



Donor Summary Details-Clinical Information Weight



Donor Summary Details-Clinical Information BMI



Donor Summary Details-KPD Information Is this a non-directed donor?



Donor Summary Details-KPD Information Intended KPD Candidate ID



Donor Summary Details-KPD Information Candidate name This field is read-only and only displays if the donor is a non-directed donor.



Donor Summary Details-KPD Information Donor's relationship to candidate



Donor Summary Details-KPD Information Are you willing to start a chain that continues with a bridge donor?



Donor Summary Details-KPD Information Does the donor have health insurance?



Donor Summary Details-KPD Information Has the donor signed the Agreement to participate in the KPD Pilot Program?



Donor Summary Details-KPD Information Has the donor signed a HIPAA form so that medical information may be shared?



Donor Summary Details-KPD Information Has the donor signed a living donor consent form as outlined in the KPD Operational Guidelines?



Donor Summary Details-KPD Information Has the donor undergone an evaluation as outlined in the KPD Operational Guidelines?



Donor Summary Details-KPD Information Has the donor had all age appropriate cancer screenings as defined by the American Cancer Society?



Donor Summary Details-KPD Information KPD status



Donor Summary Details-KPD Information Inactive reason



Donor Summary Details-KPD Information Other, specify



Donor Summary Details-KPD Information Specify



Donor Summary Details-KPD Information Removal reason



Donor Summary Details-Comments Comments



Medical and Social History Home transplant center This field cannot be updated on this page.



Medical and Social History History of diabetes



Medical and Social History History of cancer



Medical and Social History Specify



Medical and Social History History of hypertension



Medical and Social History Compliant with treatment



Medical and Social History Number of medications for hypertension that the donor is on



Medical and Social History Please indicate the type of anti-hypertension medication and dosage



Medical and Social History Please indicate how long the donor has been on medication for hypertension



Medical and Social History History of coronary artery disease (CAD)



Medical and Social History Previous gastrointestinal disease



Medical and Social History Cigarette use (>20 pack years) ever



Medical and Social History Cigarette use continued in last 6 months



Medical and Social History Heavy alcohol use (2+ drinks/day)



Medical and Social History I.V. drug usage



Medical and Social History According to the OPTN policy currently in effect, does the donor have risk factors for blood-borne disease transmission?



Medical and Social History Abdominal trauma/surgery



Medical and Social History Number of arteries



Medical and Social History Number of veins



Medical and Social History Ureter



Medical and Social History-Comments Comments



Vital Signs-Vital Signs Home transplant center This field cannot be updated on this page.



Vital Signs-Vital Signs Was 24-hour blood pressure monitor used?



Vital Signs-Vital Signs Blood pressure systolic (average of 24- hour period) If YES is entered for Was 24-hour blood pressure monitor used



Vital Signs-Vital Signs Blood pressure diastolic (average of 24-hour period) If YES is entered for Was 24-hour blood pressure monitor used



Vital Signs-Vital Signs Blood pressure date start (start of 24-hour period) If YES is entered for Was 24-hour blood pressure monitor used



Vital Signs-Vital Signs Blood pressure systolic 1 If NO is entered for the Was a 24-hour blood pressure monitor used question



Vital Signs-Vital Signs Blood pressure diastolic 1 If NO is entered for the Was a 24-hour blood pressure monitor used question



Vital Signs-Vital Signs Blood pressure date 1 If NO is entered for the Was a 24-hour blood pressure monitor used question



Vital Signs-Vital Signs Blood pressure systolic 2 If NO is entered for the Was a 24-hour blood pressure monitor used question



Vital Signs-Vital Signs Blood pressure diastolic 2 If NO is entered for the Was a 24-hour blood pressure monitor used question



Vital Signs-Vital Signs Blood pressure date 2 If NO is entered for the Was a 24-hour blood pressure monitor used question



Vital Signs-Vital Signs Was a stress test performed? If NO is entered for the Was a 24-hour blood pressure monitor used question



Vital Signs-Comments Comments



Labs-Institution Home transplant center This field cannot be updated on this page



Labs-Kidney Function Date



Labs-Kidney Function Creatinine clearance (24 hours urine collection) (mL/min)



Labs-Kidney Function Date



Labs-Kidney Function GFR (isotopic method) (mL/min/1.73m2)



Labs-Lab Values HbA1c (%)



Labs-Lab Values Oral glucose tolerance test (OGTT)



Labs-Lab Values Method



Labs-Lab Values Date



Labs-Lab Values Microalbumin



Labs-Lab Values Urine protein-to-creatinine ratio



Labs-Lab Values 24 hour urine protein



Labs-Urinalysis Date



Labs-Urinalysis Color



Labs-Urinalysis Appearance



Labs-Urinalysis pH



Labs-Urinalysis Specific gravity



Labs-Urinalysis Protein



Labs-Urinalysis Glucose



Labs-Urinalysis Blood



Labs-Urinalysis RBC



Labs-Urinalysis WBC



Labs-Urinalysis Epith (%)



Labs-Urinalysis Casts



Labs-Urinalysis Bacteria



Labs-Urinalysis Leukocyte esterase



Labs-Lab Panel Date



Labs-Lab Panel Na (mEq/L)



Labs-Lab Panel K+ (mmol/L)



Labs-Lab Panel Cl (mmol/L)



Labs-Lab Panel CO2 (mmol/L)



Labs-Lab Panel BUN (mg/dL)



Labs-Lab Panel Creatinine (mg/dL)



Labs-Lab Panel Glucose (mg/dL)



Labs-Lab Panel Total bilirubin (mg/dL)



Labs-Lab Panel Direct bilirubin (mg/dL)



Labs-Lab Panel Indirect bilirubin (mg/dL)



Labs-Lab Panel SGOT AST (u/L)



Labs-Lab Panel SGPT ALT (u/L)



Labs-Lab Panel Alkaline phosphatase (u/L)



Labs-Lab Panel GGT (u/L)



Labs-Lab Panel LDH (u/L)



Labs-Lab Panel Albumin (g/dL)



Labs-Lab Panel Total protein (g/dL)



Labs-Lab Panel Prothrombin (PT) (seconds)



Labs-Lab Panel INR



Labs-Lab Panel PTT (seconds)



Labs-Lab Panel Serum amylase (u/L)



Labs-Lab Panel Serum lipase (u/L)



Labs-Complete Blood Count (CBC) Date



Labs-Complete Blood Count (CBC) WBC (thous/mcL)



Labs-Complete Blood Count (CBC) RBC (mill/mcL)



Labs-Complete Blood Count (CBC) HgB (g/dL)



Labs-Complete Blood Count (CBC) Hct (%)



Labs-Complete Blood Count (CBC) Plt (thous/mcL)



Labs-Complete Blood Count (CBC) Bands (%)



Labs-Comments Comments



Serologies Anti-CMV



Serologies EBV (VCA) (IgG)



Serologies HBsAg



Serologies Anti-HBcAb



Serologies HBsAb



Serologies Anti-HCV



Serologies Anti-HIV I/II



Serologies Anti-HTLV I/II



Serologies RPR/VDRL



Serologies EBNA



Serologies EBV (VCA) (IgM)



Serologies-Comments Comments



Tests and Attachments Please select test or attachment



Tests and Attachments-Add New Tests or Attachments Test type



Tests and Attachments-Add New Tests or Attachments Diagnostic evaluation/comments



Tests and Attachments-Add New Tests or Attachments Attach medical image



Tests and Attachments-Add New Tests or Attachments Description



Tests and Attachments-Add New Tests or Attachments Select file All fields in the Tests and Diagnoses table are read-only



Tests and Attachments-Add New Tests or Attachments (Attachments) Please select test or attachment



Tests and Attachments-Add New Tests or Attachments (Attachments) Description



Tests and Attachments-Add New Tests or Attachments (Attachments) Select File All fields in the Attachments table are read-only



Tests and Attachments-Delete Attachments Reason deleted



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



HLA-HLA Class I A



HLA-HLA Class I A



HLA-HLA Class I B



HLA-HLA Class I B



HLA-HLA Class I BW4



HLA-HLA Class I BW6



HLA-HLA Class I C



HLA-HLA Class I C



HLA-HLA Class II DR



HLA-HLA Class II DR



HLA-HLA Class II DR51



HLA-HLA Class II DR51



HLA-HLA Class II DR52



HLA-HLA Class II DR52



HLA-HLA Class II DR53



HLA-HLA Class II DR53



HLA-HLA Class II DQB1



HLA-HLA Class II DQB1



HLA-HLA Class II DQA1



HLA-HLA Class II DQA1



HLA-HLA Class II DPB1



HLA-HLA Class II DPB1



HLA-Comments Comments



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



Donor Choices-KPD Donor Choices Donor willing to travel?



Donor Choices-KPD Donor Choices If Yes, to which center(s) is the donor willing to travel?



Donor Choices-KPD Donor Choices Is the donor willing to have his or her kidney shipped?



Donor Choices-KPD Donor Choices This donor can ONLY donate his or her following kidney



Donor Choices-KPD Donor Choices Pair and center willing to participate in a 3-way match?



Donor Choices-KPD Donor Choices Pair and center willing to participate in a chain (not as a bridge donor)?



Donor Choices-KPD Donor Choices If matched with an opportunity to be a bridge donor, does the donor consent and the center agree to continue the chain as a bridge donor?



Verify Donor ABO Subtype-Institution Home transplant center This field cannot be updated on this page



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



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



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



Verify Donor ABO-Donor Information ABO



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



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



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



Verify Donor ABO Subtype-Institution Home transplant center This field cannot be updated on this page



Verify Donor ABO Subtype-Donor Information Last name This field is read-only



Verify Donor ABO Subtype-Donor Information First name This field is read-only



Verify Donor ABO Subtype-Donor Information Middle initial This field is read-only



Verify Donor ABO Subtype-Donor Information ABO



Verify Donor ABO Subtype-Donor Information Age This field is read-only



Verify Donor ABO Subtype-Donor Information Gender This field is read-only



Verify Donor ABO Subtype-Donor Information First ABO subtype user This field is read-only



Manage Bridge Donors-Pending Bridge Donors Select home transplant center



Manage Bridge Donors-Pending Bridge Donors KPD donor ID This field is read-only



Manage Bridge Donors-Pending Bridge Donors Donor name This field is read-only



Manage Bridge Donors-Pending Bridge Donors Match run date donor became a bridge donor This field is read-only



Manage Bridge Donors-Pending Bridge Donors Bridge donor on hold This field is optional



Manage Bridge Donors-Pending Bridge Donors Access bridge donor record



Manage Bridge Donors-Pending Bridge Donors Exchange number This field is read-only



Manage Bridge Donor Record Home transplant center



Manage Bridge Donor Record KPD donor ID This field is read-only



Manage Bridge Donor Record Donor name This field is read-only



Manage Bridge Donor Record Bridge donor status



Manage Bridge Donor Record Bridge donor status date



Manage Bridge Donor Record Bridge donor on hold This field is optional



Manage Bridge Donor Record KPD donor status This field is read-only



Manage Bridge Donor Record Match run date donor became a bridge donor This field is read-only



Manage Bridge Donor Record Exchange number This field is read-only



Manage Bridge Donor Record-Bridge donor status: Declined to donate reason Bridge donor status declined to donate reasons



Manage Bridge Donor Record-Bridge donor status: Declined to donate reason Life circumstances have changed



Manage Bridge Donor Record-Bridge donor status: Declined to donate reason Medical condition has changed



Manage Bridge Donor Record-Bridge donor status: Declined to donate reason Other reasons



Manage Bridge Donor Record-Bridge donor status: Declined to donate reason Enter Comments





















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].








































File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy