61 Potential Disease Transmission Report_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Potential Disease Transmission Report_Form.xlsx

Potential Disease Transmission Report

OMB: 0915-0157

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Potential Disease Transmission Report



Fields to be completed by members







Form Section Field Label Notes



Disease Transmission Event ID & Donor ID Disease Transmission Event ID



Disease Transmission Event ID & Donor ID Donor ID



PDTR Contact Information - Person Submitting This Report First Name



PDTR Contact Information - Person Submitting This Report Last Name



PDTR Contact Information - Person Submitting This Report E-mail



PDTR Contact Information - Person Submitting This Report Phone



Information The following Suspected Organism/Diseases(s) were reported



Information Additional Comments



Information As of today, the transmission is



Information Date of Recovery



Status of Infection/Disease in Donor Donor symptomatic prior to procurement?



Status of Infection/Disease in Donor Known at procurement?



Status of Infection/Disease in Donor Was an autopsy performed on the donor?



Status of Infection/Disease in Donor What type of donor specimen(s)/samples are available for further testing?



Status of Infection/Disease in Donor Was the donor blood sample obtained pre- or post-transfusion?



Status of Infection/Disease in Donor If the sample was obtained post-transfusion, were hemodilution calculations performed?



Status of Infection/Disease in Donor Were all specimens saved for further testing (donor hospital, OPO, and Tx Center)?



Status of Infection/Disease in Donor If blood specimens are available on the donor for testing, how much?



Procuring/Host OPO Contact Information First Name



Procuring/Host OPO Contact Information Last Name



Procuring/Host OPO Contact Information Phone



Procuring/Host OPO Contact Information Other



Reporting Status - Public Health Authority Contact Information Have the public health authorities been contacted?



Reporting Status - Public Health Authority Contact Information First Name



Reporting Status - Public Health Authority Contact Information Last Name



Reporting Status - Public Health Authority Contact Information Phone



Reporting Status - Public Health Authority Contact Information Phone Ext



Assay Test Was an assay and/or other test used to identify organism/disease?



Assay Test Date of Test



Assay Test Results



Assay Test Assay/Test Type



Organs - Heart Organ/Vessels Recovered



Organs - Heart Heart



Organs - Heart Organ Disposition



Organs - Heart Associated Vessels Disposition



Organs - Heart Contacted by OPO?



Organs - Heart Date Contacted



Organs - Heart Center Name



Organs - Heart Contact First Name



Organs - Heart Contact Last Name



Organs - Heart Contact Email



Organs - Heart Contact Phone Number



Organs - Lung - Left Organ/Vessels Recovered



Organs - Lung - Left Lung - Left



Organs - Lung - Left Organ Disposition



Organs - Lung - Left Associated Vessels Disposition



Organs - Lung - Left Contacted by OPO?



Organs - Lung - Left Date Contacted



Organs - Lung - Left Center Name



Organs - Lung - Left Contact First Name



Organs - Lung - Left Contact Last Name



Organs - Lung - Left Contact Email



Organs - Lung - Left Contact Phone Number



Organs - Lung - Right Organ/Vessels Recovered



Organs - Lung - Right Lung - Right



Organs - Lung - Right Organ Disposition



Organs - Lung - Right Associated Vessels Disposition



Organs - Lung - Right Contacted by OPO?



Organs - Lung - Right Date Contacted



Organs - Lung - Right Center Name



Organs - Lung - Right Contact First Name



Organs - Lung - Right Contact Last Name



Organs - Lung - Right Contact Email



Organs - Lung - Right Contact Phone Number



Organs - Liver - Whole Organ/Vessels Recovered



Organs - Liver - Whole Liver - Whole



Organs - Liver - Whole Organ Disposition



Organs - Liver - Whole Associated Vessels Disposition



Organs - Liver - Whole Contacted by OPO?



Organs - Liver - Whole Date Contacted



Organs - Liver - Whole Center Name



Organs - Liver - Whole Contact First Name



Organs - Liver - Whole Contact Last Name



Organs - Liver - Whole Contact Email



Organs - Liver - Whole Contact Phone Number



Organs - Liver - Segment 1 Organ/Vessels Recovered



Organs - Liver - Segment 1 Liver - Segment 1



Organs - Liver - Segment 1 Organ Disposition



Organs - Liver - Segment 1 Associated Vessels Disposition



Organs - Liver - Segment 1 Contacted by OPO?



Organs - Liver - Segment 1 Date Contacted



Organs - Liver - Segment 1 Center Name



Organs - Liver - Segment 1 Contact First Name



Organs - Liver - Segment 1 Contact Last Name



Organs - Liver - Segment 1 Contact Email



Organs - Liver - Segment 1 Contact Phone Number



Organs - Liver - Segment 2 Organ/Vessels Recovered



Organs - Liver - Segment 2 Liver - Segment 2



Organs - Liver - Segment 2 Organ Disposition



Organs - Liver - Segment 2 Associated Vessels Disposition



Organs - Liver - Segment 2 Contacted by OPO?



Organs - Liver - Segment 2 Date Contacted



Organs - Liver - Segment 2 Center Name



Organs - Liver - Segment 2 Contact First Name



Organs - Liver - Segment 2 Contact Last Name



Organs - Liver - Segment 2 Contact Email



Organs - Liver - Segment 2 Contact Phone Number



Organs - Intestine - Whole Organ/Vessels Recovered



Organs - Intestine - Whole Intestine - Whole



Organs - Intestine - Whole Organ Disposition



Organs - Intestine - Whole Associated Vessels Disposition



Organs - Intestine - Whole Contacted by OPO?



Organs - Intestine - Whole Date Contacted



Organs - Intestine - Whole Center Name



Organs - Intestine - Whole Contact First Name



Organs - Intestine - Whole Contact Last Name



Organs - Intestine - Whole Contact Email



Organs - Intestine - Whole Contact Phone Number



Organs - Intestine - Segment 1 Organ/Vessels Recovered



Organs - Intestine - Segment 1 Intestine - Segment 1



Organs - Intestine - Segment 1 Organ Disposition



Organs - Intestine - Segment 1 Associated Vessels Disposition



Organs - Intestine - Segment 1 Contacted by OPO?



Organs - Intestine - Segment 1 Date Contacted



Organs - Intestine - Segment 1 Center Name



Organs - Intestine - Segment 1 Contact First Name



Organs - Intestine - Segment 1 Contact Last Name



Organs - Intestine - Segment 1 Contact Email



Organs - Intestine - Segment 1 Contact Phone Number



Organs - Intestine - Segment 2 Organ/Vessels Recovered



Organs - Intestine - Segment 2 Intestine - Segment 2



Organs - Intestine - Segment 2 Organ Disposition



Organs - Intestine - Segment 2 Associated Vessels Disposition



Organs - Intestine - Segment 2 Contacted by OPO?



Organs - Intestine - Segment 2 Date Contacted



Organs - Intestine - Segment 2 Center Name



Organs - Intestine - Segment 2 Contact First Name



Organs - Intestine - Segment 2 Contact Last Name



Organs - Intestine - Segment 2 Contact Email



Organs - Intestine - Segment 2 Contact Phone Number



Organs - Pancreas - Whole Organ/Vessels Recovered



Organs - Pancreas - Whole Pancreas - Whole



Organs - Pancreas - Whole Organ Disposition



Organs - Pancreas - Whole Associated Vessels Disposition



Organs - Pancreas - Whole Contacted by OPO?



Organs - Pancreas - Whole Date Contacted



Organs - Pancreas - Whole Center Name



Organs - Pancreas - Whole Contact First Name



Organs - Pancreas - Whole Contact Last Name



Organs - Pancreas - Whole Contact Email



Organs - Pancreas - Whole Contact Phone Number



Organs - Pancreas - Segment 1 Organ/Vessels Recovered



Organs - Pancreas - Segment 1 Pancreas - Segment 1



Organs - Pancreas - Segment 1 Organ Disposition



Organs - Pancreas - Segment 1 Associated Vessels Disposition



Organs - Pancreas - Segment 1 Contacted by OPO?



Organs - Pancreas - Segment 1 Date Contacted



Organs - Pancreas - Segment 1 Center Name



Organs - Pancreas - Segment 1 Contact First Name



Organs - Pancreas - Segment 1 Contact Last Name



Organs - Pancreas - Segment 1 Contact Email



Organs - Pancreas - Segment 1 Contact Phone Number



Organs - Pancreas - Segment 2 Organ/Vessels Recovered



Organs - Pancreas - Segment 2 Pancreas - Segment 2



Organs - Pancreas - Segment 2 Organ Disposition



Organs - Pancreas - Segment 2 Associated Vessels Disposition



Organs - Pancreas - Segment 2 Contacted by OPO?



Organs - Pancreas - Segment 2 Date Contacted



Organs - Pancreas - Segment 2 Center Name



Organs - Pancreas - Segment 2 Contact First Name



Organs - Pancreas - Segment 2 Contact Last Name



Organs - Pancreas - Segment 2 Contact Email



Organs - Pancreas - Segment 2 Contact Phone Number



Organs - Pancreas - Islet Cells Organ/Vessels Recovered



Organs - Pancreas - Islet Cells Organ Disposition



Organs - Pancreas - Islet Cells Associated Vessels Disposition



Organs - Pancreas - Islet Cells Contacted by OPO?



Organs - Pancreas - Islet Cells Date Contacted



Organs - Pancreas - Islet Cells Center Name



Organs - Pancreas - Islet Cells Contact First Name



Organs - Pancreas - Islet Cells Contact Last Name



Organs - Pancreas - Islet Cells Contact Email



Organs - Pancreas - Islet Cells Contact Phone Number



Organs - Kidney - Right Organ/Vessels Recovered



Organs - Kidney - Right Kidney - Right



Organs - Kidney - Right Organ Disposition



Organs - Kidney - Right Associated Vessels Disposition



Organs - Kidney - Right Contacted by OPO?



Organs - Kidney - Right Date Contacted



Organs - Kidney - Right Center Name



Organs - Kidney - Right Contact First Name



Organs - Kidney - Right Contact Last Name



Organs - Kidney - Right Contact Email



Organs - Kidney - Right Contact Phone Number



Organs - Kidney - Left Organ/Vessels Recovered



Organs - Kidney - Left Kidney - Left



Organs - Kidney - Left Organ Disposition



Organs - Kidney - Left Associated Vessels Disposition



Organs - Kidney - Left Contacted by OPO?



Organs - Kidney - Left Date Contacted



Organs - Kidney - Left Center Name



Organs - Kidney - Left Contact First Name



Organs - Kidney - Left Contact Last Name



Organs - Kidney - Left Contact Email



Organs - Kidney - Left Contact Phone Number



Vascular Composite Allograft - VCA - Abdominal Wall Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Abdominal Wall VCA - Abdominal Wall



Vascular Composite Allograft - VCA - Abdominal Wall Organ Disposition



Vascular Composite Allograft - VCA - Abdominal Wall Contacted by OPO?



Vascular Composite Allograft - VCA - Abdominal Wall Date Contacted



Vascular Composite Allograft - VCA - Abdominal Wall Center Name



Vascular Composite Allograft - VCA - Abdominal Wall Contact First Name



Vascular Composite Allograft - VCA - Abdominal Wall Contact Last Name



Vascular Composite Allograft - VCA - Abdominal Wall Contact Email



Vascular Composite Allograft - VCA - Abdominal Wall Contact Phone Number



Vascular Composite Allograft - VCA - Head and Neck Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Head and Neck VCA - Head and neck



Vascular Composite Allograft - VCA - Head and Neck Organ Disposition



Vascular Composite Allograft - VCA - Head and Neck Contacted by OPO?



Vascular Composite Allograft - VCA - Head and Neck Date Contacted



Vascular Composite Allograft - VCA - Head and Neck Center Name



Vascular Composite Allograft - VCA - Head and Neck Contact First Name



Vascular Composite Allograft - VCA - Head and Neck Contact Last Name



Vascular Composite Allograft - VCA - Head and Neck Contact Email



Vascular Composite Allograft - VCA - Head and Neck Contact Phone Number



Vascular Composite Allograft - VCA - Upper Limb Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Upper Limb VCA - Upper Limb



Vascular Composite Allograft - VCA - Upper Limb Organ Disposition



Vascular Composite Allograft - VCA - Upper Limb Contacted by OPO?



Vascular Composite Allograft - VCA - Upper Limb Date Contacted



Vascular Composite Allograft - VCA - Upper Limb Center Name



Vascular Composite Allograft - VCA - Upper Limb Contact First Name



Vascular Composite Allograft - VCA - Upper Limb Contact Last Name



Vascular Composite Allograft - VCA - Upper Limb Contact Email



Vascular Composite Allograft - VCA - Upper Limb Contact Phone Number



Vascular Composite Allograft - VCA - Lower Limb Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Lower Limb VCA - Lower Limb



Vascular Composite Allograft - VCA - Lower Limb Organ Disposition



Vascular Composite Allograft - VCA - Lower Limb Contacted by OPO?



Vascular Composite Allograft - VCA - Lower Limb Date Contacted



Vascular Composite Allograft - VCA - Lower Limb Center Name



Vascular Composite Allograft - VCA - Lower Limb Contact First Name



Vascular Composite Allograft - VCA - Lower Limb Contact Last Name



Vascular Composite Allograft - VCA - Lower Limb Contact Email



Vascular Composite Allograft - VCA - Lower Limb Contact Phone Number



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment VCA - Musculoskeletal Composite Graft Segment



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Organ Disposition



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Contacted by OPO?



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Date Contacted



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Center Name



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Contact First Name



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Contact Last Name



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Contact Email



Vascular Composite Allograft - VCA - Musculoskeletal Composite Graft Segment Contact Phone Number



Vascular Composite Allograft - VCA - Spleen Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Spleen VCA - Spleen



Vascular Composite Allograft - VCA - Spleen Organ Disposition



Vascular Composite Allograft - VCA - Spleen Contacted by OPO?



Vascular Composite Allograft - VCA - Spleen Date Contacted



Vascular Composite Allograft - VCA - Spleen Center Name



Vascular Composite Allograft - VCA - Spleen Contact First Name



Vascular Composite Allograft - VCA - Spleen Contact Last Name



Vascular Composite Allograft - VCA - Spleen Contact Email



Vascular Composite Allograft - VCA - Spleen Contact Phone Number



Vascular Composite Allograft - VCA - Glands Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Glands VCA - Glands



Vascular Composite Allograft - VCA - Glands Organ Disposition



Vascular Composite Allograft - VCA - Glands Contacted by OPO?



Vascular Composite Allograft - VCA - Glands Date Contacted



Vascular Composite Allograft - VCA - Glands Center Name



Vascular Composite Allograft - VCA - Glands Contact First Name



Vascular Composite Allograft - VCA - Glands Contact Last Name



Vascular Composite Allograft - VCA - Glands Contact Email



Vascular Composite Allograft - VCA - Glands Contact Phone Number



Vascular Composite Allograft - VCA - Genitourinary Organs Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Genitourinary Organs VCA - Genitourinary Organs



Vascular Composite Allograft - VCA - Genitourinary Organs Organ Disposition



Vascular Composite Allograft - VCA - Genitourinary Organs Contacted by OPO?



Vascular Composite Allograft - VCA - Genitourinary Organs Date Contacted



Vascular Composite Allograft - VCA - Genitourinary Organs Center Name



Vascular Composite Allograft - VCA - Genitourinary Organs Contact First Name



Vascular Composite Allograft - VCA - Genitourinary Organs Contact Last Name



Vascular Composite Allograft - VCA - Genitourinary Organs Contact Email



Vascular Composite Allograft - VCA - Genitourinary Organs Contact Phone Number



Vascular Composite Allograft - VCA - Other Vascular composite allograft (VCA) recovered?



Vascular Composite Allograft - VCA - Other VCA - Other



Vascular Composite Allograft - VCA - Other Organ Disposition



Vascular Composite Allograft - VCA - Other VCA Other Describe



Vascular Composite Allograft - VCA - Other Contacted by OPO?



Vascular Composite Allograft - VCA - Other Date Contacted



Vascular Composite Allograft - VCA - Other Center Name



Vascular Composite Allograft - VCA - Other Contact First Name



Vascular Composite Allograft - VCA - Other Contact Last Name



Vascular Composite Allograft - VCA - Other Contact Email



Vascular Composite Allograft - VCA - Other Contact Phone Number



Tissues - Blood Vessels - Femoral Tissues recovered?



Tissues - Blood Vessels - Femoral Blood Vessels - Femoral



Tissues - Blood Vessels - Femoral Organ Disposition



Tissues - Blood Vessels - Femoral Contacted by OPO?



Tissues - Blood Vessels - Femoral Date Contacted



Tissues - Blood Vessels - Femoral Center Name



Tissues - Blood Vessels - Femoral Contact First Name



Tissues - Blood Vessels - Femoral Contact Last Name



Tissues - Blood Vessels - Femoral Contact Email



Tissues - Blood Vessels - Femoral Contact Phone Number



Tissues - Blood Vessels - Iliac Tissues recovered?



Tissues - Blood Vessels - Iliac Blood Vessels - Iliac



Tissues - Blood Vessels - Iliac Organ Disposition



Tissues - Blood Vessels - Iliac Contacted by OPO?



Tissues - Blood Vessels - Iliac Date Contacted



Tissues - Blood Vessels - Iliac Center Name



Tissues - Blood Vessels - Iliac Contact First Name



Tissues - Blood Vessels - Iliac Contact Last Name



Tissues - Blood Vessels - Iliac Contact Email



Tissues - Blood Vessels - Iliac Contact Phone Number



Tissues - Blood Vessels - Other Tissues recovered?



Tissues - Blood Vessels - Other Blood Vessels - Other



Tissues - Blood Vessels - Other Organ Disposition



Tissues - Blood Vessels - Other Contacted by OPO?



Tissues - Blood Vessels - Other Date Contacted



Tissues - Blood Vessels - Other Center Name



Tissues - Blood Vessels - Other Contact First Name



Tissues - Blood Vessels - Other Contact Last Name



Tissues - Blood Vessels - Other Contact Email



Tissues - Blood Vessels - Other Contact Phone Number



Tissues - Bone Tissues recovered?



Tissues - Bone Tissues - Bone



Tissues - Bone Organ Disposition



Tissues - Bone Contacted by OPO?



Tissues - Bone Date Contacted



Tissues - Bone Center Name



Tissues - Bone Contact First Name



Tissues - Bone Contact Last Name



Tissues - Bone Contact Email



Tissues - Bone Contact Phone Number



Tissues - Fascia Tissues recovered?



Tissues - Fascia Tissues - Fascia



Tissues - Fascia Organ Disposition



Tissues - Fascia Contacted by OPO?



Tissues - Fascia Date Contacted



Tissues - Fascia Center Name



Tissues - Fascia Contact First Name



Tissues - Fascia Contact Last Name



Tissues - Fascia Contact Email



Tissues - Fascia Contact Phone Number



Tissues - Skin Tissues recovered?



Tissues - Skin Tissues - Skin



Tissues - Skin Organ Disposition



Tissues - Skin Contacted by OPO?



Tissues - Skin Date Contacted



Tissues - Skin Center Name



Tissues - Skin Contact First Name



Tissues - Skin Contact Last Name



Tissues - Skin Contact Email



Tissues - Skin Contact Phone Number



Tissues - Tendons Tissues recovered?



Tissues - Tendons Tissues - Tendons



Tissues - Tendons Organ Disposition



Tissues - Tendons Contacted by OPO?



Tissues - Tendons Date Contacted



Tissues - Tendons Center Name



Tissues - Tendons Contact First Name



Tissues - Tendons Contact Last Name



Tissues - Tendons Contact Email



Tissues - Tendons Contact Phone Number



Tissues - Heart Valves Tissues recovered?



Tissues - Heart Valves Tissues - Heart Valves



Tissues - Heart Valves Organ Disposition



Tissues - Heart Valves Contacted by OPO?



Tissues - Heart Valves Date Contacted



Tissues - Heart Valves Center Name



Tissues - Heart Valves Contact First Name



Tissues - Heart Valves Contact Last Name



Tissues - Heart Valves Contact Email



Tissues - Heart Valves Contact Phone Number



Tissues - Eyes/Corneas Tissues recovered?



Tissues - Eyes/Corneas Tissues - Eyes/Corneas



Tissues - Eyes/Corneas Organ Disposition



Tissues - Eyes/Corneas Contacted by OPO?



Tissues - Eyes/Corneas Date Contacted



Tissues - Eyes/Corneas Center Name



Tissues - Eyes/Corneas Contact First Name



Tissues - Eyes/Corneas Contact Last Name



Tissues - Eyes/Corneas Contact Email



Tissues - Eyes/Corneas Contact Phone Number



Tissues - Tissue Other Tissues recovered?



Tissues - Tissue Other Tissues - Tissue Other



Tissues - Tissue Other Organ Disposition



Tissues - Tissue Other Tissue Other Describe



Tissues - Tissue Other Contacted by OPO?



Tissues - Tissue Other Date Contacted



Tissues - Tissue Other Center Name



Tissues - Tissue Other Contact First Name



Tissues - Tissue Other Contact Last Name



Tissues - Tissue Other Contact Email



Tissues - Tissue Other Contact Phone Number





















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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