57 Kidney Paired Donation Match Offer Management_Form.xlsx

			Kidney Paired Donation Match Offer Management Form
			Fields to be completed by members
			Form Section	Field Label	Notes
			Match Response	Match Run Number	System generated each time match is executed. This field is read-only
			Match Response	Match Run Date	This field is read-only
			Match Response	Exchange Number	System generated. This field is read-only
			Match Response	Match ID	System generated. This field is read-only
			Match Response	Matched donor ID	System generated. This field is read-only
			Match Response	Donor name	This field is read-only
			Match Response	KPD candidate ID	System generated. This field is read-only
			Match Response	Candidate name	This field is read-only
			Match Response	Candidate center	This field is read-only
			Match Response	Paired donor at the end of a chain	The value is determined by the system. This field is read-only
			Match Response	Match state	System determined. This field is read-only
			Match Response Preliminary Response	Preliminary response
			Match Response (preliminary acceptance) Crossmatch Results	Crossmatch results
			Match Response (preliminary acceptance) Crossmatch Results	Crossmatch date
			Match Response (preliminary acceptance) Crossmatch Results	Match status
			Match Response (preliminary refuse) Match status (match did not result in a transplant)	Match status
			Match Response (preliminary refuse) Match status (match did not result in a transplant)	Primary reason	This field only displays if the preliminary response is set to Refuse
			Match Response (preliminary refuse) Match status (match did not result in a transplant)	Secondary reason	This field is optional
			Match Response (preliminary refuse) Match status (match did not result in a transplant)	Future matching: Would your candidate be willing to match to this donor in a future match run?
			Match Response (preliminary refuse) Match status (match did not result in a transplant)	Primary reason – Other, specify
			Match Response (preliminary refuse) Match status (match did not result in a transplant)	Secondary reason – Other, specify
			Select Exchange Ending Donor	Match run number	System generated each time match is executed. This field is read-only
			Select Exchange Ending Donor	Match run date	This field is read-only
			Select Exchange Ending Donor	Exchange number	System generated. This field is read-only
			Select Exchange Ending Donor	Selected
			Select Exchange Ending Donor	KPD donor ID
			Select Exchange Ending Donor	Donor name
			Select Exchange Ending Donor	Age
			Select Exchange Ending Donor	BMI
			Select Exchange Ending Donor	ABO
			Select Exchange Ending Donor	Bridge
			Select Exchange Ending Donor	Kidney choice
			Select Exchange Ending Donor	Number of arteries
			Select Exchange Ending Donor	Number of veins
			Exchange ending donor donating to the Waitlist (refusal)	Preliminary response
			Exchange ending donor donating to the Waitlist (refusal)	Match status
			Enter the reason(s) the match did not result in a transplant	Primary reason
			Enter the reason(s) the match did not result in a transplant	Secondary reason
			Exchange ending donor donating to the Waitlist (preliminary acceptance)	Preliminary response
			Exchange ending donor donating to the Waitlist (preliminary acceptance)	Match status
			Exchange Message Board Exchange Information	Match run number	System generated each time match is executed. This field is read-only
			Exchange Message Board Exchange Information	Match run date	This field is read-only
			Exchange Message Board Exchange Information	Exchange number	System generated. This field is read-only
			Exchange Message Board Exchange Information	Match ID	System generated. This field is read-only
			Exchange Message Board Exchange Information	Matched donor ID	System generated. This field is read-only
			Exchange Message Board Exchange Information	Donor name	This field is read-only
			Exchange Message Board Exchange Information	Donor center	This field is read-only
			Exchange Message Board Exchange Information	KPD candidate ID	System generated. This field is read-only
			Exchange Message Board Exchange Information	Candidate name	This field is read-only
			Exchange Message Board Exchange Information	Candidate center	This field is read-only
			Exchange Message Board Exchange activity dates	Match state	This field is read-only
			Exchange Message Board Exchange activity dates	When will crossmatches will be performed?
			Exchange Message Board Exchange activity dates	When were donor records available to the candidate hospital?
			Exchange Message Board Exchange activity dates	Crossmatch results	This field is read-only
			Exchange Message Board Exchange activity dates	When was donor acceptance confirmed?
			Exchange Message Board Exchange activity dates	Surgery scheduled for:	This field is read-only
			Exchange Message Board Message History	Alert me by email when new messages are posted
			Exchange Message Board Message History	Add message
			Exchange Message Board Message History	#	This field is read-only and generated by the system each time a message post is created
			Exchange Message Board Message History	Date/time	This field is read-only and generated by the system each time a message post is created
			Exchange Message Board Message History	Posted by	This field is read-only and generated by the system
			Exchange Message Board Message History	Center code	This field is read-only and generated by the system each time a message is created
			Exchange Message Board Message History	Exchange name	This field is read-only and generated by the system each time an exchange is created
			Exchange Message Board Message History	Message text	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].