59 Living Donor Event_Form.xlsx

			Living Donor Event
			Fields to be completed by members
			Form Section	Field Label	Notes
			Event Information	Living Donor ID
			Event Information	Living Donor Event (Choose all categories and subcategories that are applicable)
			Event Information	Recovery surgery aborted after donor received anesthesia (Please describe in the Description field below):
			Event Information	Living Donor dies within two years after organ donation
			Event Information	Living liver or kidney donor is listed on the waitlist within two years after organ donation
			Event Information	Select non-functioning organ
			Event Information	Listing transplant center
			Event Information	Date listed
			Event Information	Living kidney donor on regularly administered dialysis as an ESRD patient within two years after organ donation
			Event Information	Organ is recovered but not transplanted into any recipient
			Event Information	Organ is recovered and transplanted into someone other than the intended recipient
			Event Information	Other (Events that do not fall under the above categories may be reported here. Please describe in Description field below.)
			Event Information	Date of Event
			Event Information	Date Reporting Member Aware of Event
			Event Information	Did the event occur at an institution?
			Event Information	At which institution did the event occur?
			Event Information	Reporting Institution
			Event Information	Description
			Contact Information	Who is the patient safety contact at your institution for this event? First Name
			Contact Information	Last Name
			Contact Information	Phone contact (Enter at least one) Office
			Contact Information	ext.
			Contact Information	Mobile
			Contact Information	ext.
			Contact Information	Email
			Contact Information	Other contact info
			Contact Information	ext.
			Contact Information	First Name
			Contact Information	Last Name
			Contact Information	Email
			Contact Information	Submit
			Contact Information	Cancel
			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].