Potential Disease Transmission Report

^{Potential Disease Transmission Report} Field Descriptions

Potential disease transmissions become part of a confidential medical peer review process. The OPTN Ad Hoc Disease Transmission Advisory Committee (DTAC) examines individual potential disease transmission cases reported to the OPTN in an effort to confirm transmissions of donor origin whenever possible.

The initial report documents the OPO’s communication of the donor information to all transplant centers that utilized organs from the donor associated with the reported event. The report will be submitted for review by the DTAC. It is necessary to receive this document within 24 hours of the reported event into the Patient Safety System, in an effort to collect critical, time-sensitive information regarding the donor, organs, tissues, and extra vessels that were procured. The OPO should include all contact information for recipient center(s), tissue, and/or eye banks that have been notified of the potential for disease or malignancy transmission.

All fields on the initial report should be completed with the information available at the time of submission. It is acceptable that all information may not be available to submit within 24 hours of the report to the Patient Safety System.

Section: Disease Transmission Event ID & Donor ID

Disease Transmission Event ID: The disease transmission event ID displays. You can find this ID within the Patient Safety Portal or Event Notification/Acknowledgment e-mail. This field is required.

Donor ID: Enter the seven-digit donor ID. This ID consists of letters and numbers. This field is required.

Click the Submit and Continue button to proceed.

Section: PDTR Contact Information – Person Submitting This Report

First Name: Enter the first name of the person submitting the form. Alphanumeric up to 50 characters. This field is required.

Last Name: Enter the last name of the person submitting the form. Alphanumeric up to 50 characters. This field is required.

E-mail: Enter the e-mail address of the person submitting the form. Alphanumeric up to 80 characters. This field is required.

Phone: Enter the phone number of the person submitting the form. Alphanumeric up to 10 characters. This field is required.

Section: Information

The following Suspected Organism/Disease(s) were reported: The suspected organism or disease reported displays in read-only format.

Additional Comments: Enter additional information in the text box. If recipients of organs or vessels are deceased prior to the reported event, please also include this information in the comment section on the report. Alphanumeric up to 10,000 characters.

As of today, the transmission is: Select the response from the drop-down list of options. This field is required. If required fields are not applicable to this case or if information is unknown, select Unknown in the answer field.
(Values: Suspected, Confirmed, Unknown)

Date of Recovery: The date of recovery displays in read-only format.

Section: Status of Infection/Disease in Donor

Donor symptomatic prior to procurement?: Select the Yes or No radio button. This field is required.

Known at procurement?: Select the Yes or No radio button. This field is required.

Was an autopsy performed on the donor?: Select the Yes, No or Unknown radio button. This field is required.
Note: If an autopsy was completed or will be performed on the donor, please attach a copy to the event or email to the Patient Safety Coordinators once it is completed.

What type of donor specimen(s)/samples are available for further testing?: Enter the type of donor specimen or samples that are available for further testing. Alphanumeric up to 255 characters. This field is required.

Was the donor blood sample obtained pre- or post-transfusion?: Select the radio button. This field is required.

(Values: Pre-transfusion, Post-transfusion, N/A)

If the sample was obtained post-transfusion, were hemodilution calculations performed?: Select the Yes or No radio button. This field is required.

Were all specimens saved for further testing (donor hospital, OPO, and TX Center)?: Select the Yes or No radio button. This field is required.

If blood specimens are available on the donor for testing, how much?: Enter the amount of blood specimens available for testing. Alphanumeric up to 255 characters. This field is required.

Section: Procuring/Host OPO Contact Information

First Name: Enter the first name of the OPO contact. Alphanumeric up to 50 characters. This field is required.

Last Name: Enter the last name of the OPO contact. Alphanumeric up to 50 characters. This field is required.

Phone: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters. This field is required.

Other: Enter additional information. Alphanumeric up to 40 characters.

Section: Reporting Status – Public Health Authority Contact Information

Have the public health authorities been contacted?: Select the Yes or No radio button. If yes, complete the following fields:

First Name: Enter the first name of the public health authority contact. Alphanumeric up to 100 characters. This field is required.

Last Name: Enter the last name of the public health authority contact. This field is required.

Phone: Enter the phone number of the public health authority contact. Alphanumeric up to 10 characters. This field is required.

Phone Ext: Enter the phone number extension of the public health authority contact. Alphanumeric up to 50 characters.

Section: Assay Test

Was an assay and/or other test used to identify organism/disease?: Select Yes, No or Unknown. This field is required. If required fields are not applicable to this case or if information is unknown, select Unknown in the answer field. If yes, complete the following fields:

Date of Test: Enter the date of the test. MM/DD/YYYY format.

Results: Select the response from the drop-down list of options. This field is required.
(Values: Positive, Negative, Indeterminate, Other)

Assay/Test Type: Select the response from the drop-down list of options. This field is required.
(Values: Ab, Acid Fast Smear, Aerobic Cx, AFB Cx, BAL, Blood Cx, Bone Marrow Bx, Bronchial Bx, Bronchial Lavage, Bx, Cell block, Cell Ct & Diff, CMV Stain, CT of abd, CT of chest, CT of head, CT of pelvis, CXR, Cytology, DNA testing, FISH, Fluid Cx, Fungal Cx, Fungal Stain, GMS stains, Gram Stain, IgG, IgM, Legionella DFA & Cx, Molecular Fingerprinting, MRI of abd, MRI of chest, MRI of head, MRI of pelvis, NAT, PCR, Pneumocystis IFA, Pneumocystis Stain, PPD, Silver Stain, Smear, Sputum Cx, Surface Antigen, Urinalysis, Urine Cx, US of abd, US of pelvis, Viral Cx, RNA, Other Specify)

Note: If you need to add another Assay/Test, please click on the Add Additional Assay/Tests link below right.

Section: Organs – Heart

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:
Heart: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.

Section: Organs – Lung – Left

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Lung - Left: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Lung – Right

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Lung - Right: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the OPO contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the OPO contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.

Section: Organs – Liver – Whole

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Liver - Whole: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Liver – Segment 1

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Liver – Segment 1: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.

Section: Organs – Liver – Segment 2

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Liver – Segment 2: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:
Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Intestine – Whole

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Intestine - Whole: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Intestine – Segment 1

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Intestine – Segment 1: Select the Yes or No radio button. This field is required. If yes, complete the following fields:
Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Intestine – Segment 2

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Intestine – Segment 2: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Pancreas – Whole

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Pancreas – Whole: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.

Section: Organs – Pancreas – Segment 1

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Pancreas – Segment 1: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Pancreas – Segment 2

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Pancreas – Segment 2: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Pancreas – Islet Cells

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Kidney – Right

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Kidney – Right: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Organs – Kidney – Left

Organ/Vessels Recovered: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Kidney – Left: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Associated Vessels Disposition: Select the radio button. This field is required.

(Values: Transplanted, Stored, Quarantined, Discarded, N/A, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Abdominal Wall

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Abdominal Wall: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Head and Neck

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Head and Neck: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Upper Limb

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Upper Limb: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Lower Limb

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Lower Limb: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Musculoskeletal Composite Graft Segment

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Musculoskeletal Composite Graft Segment: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Spleen

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Spleen: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Glands

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Glands: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Genitourinary Organs

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Genitourinary Organs: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Vascular Composite Allograft – VCA – Other

Vascular composite allograft (VCA) recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

VCA – Other: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Discarded, Recovered for TX, but not TX, Recovered, but not TX)

VCA Other Describe: Enter additional information in the text box. Text and numeric up to 255 characters. This field is required.

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the program contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the program contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the program contact. Alphanumeric up to 10 characters.

Section: Tissues – Blood Vessels – Femoral

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Blood Vessels - Femoral: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues – Blood Vessels – Iliac

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Blood Vessels - Iliac: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues – Blood Vessels – Other

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Blood Vessels - Other: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues – Bone

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Tissues - Bone: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues – Fascia

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Tissues - Fascia: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues - Skin

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Tissues - Skin: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues - Tendons

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Tissues - Tendons: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues – Heart Valves

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Tissues – Heart Valves: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues – Eyes/Corneas

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Tissues – Eyes/Corneas: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Section: Tissues – Tissue Other

Tissues recovered?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Tissues – Tissue Other: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Organ Disposition: Select the radio button. This field is required.
(Values: Transplanted, Stored, Quarantined, Discarded, Unknown)

Tissue Other Describe: Enter additional information in the text box. Alphanumeric up to 5,000 characters. This field is required.

Contacted by OPO?: Select the Yes or No radio button. This field is required. If yes, complete the following fields:

Date Contacted: Enter the date contacted by OPO. MM/DD/YYYY format. This field is required.

Center Name: Enter the center name. Alphanumeric up to 75 characters. This field is required.

Contact First Name: Enter the first name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Last Name: Enter the last name of the tissue bank contact. Alphanumeric up to 50 characters. This field is required.

Contact Email: Enter the email address of the tissue bank contact. Alphanumeric up to 80 characters.

Contact Phone Number: Enter the phone number of the tissue bank contact. Alphanumeric up to 10 characters.

Click Submit the PDTR button to submit the form.

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