53 Organ Labeling and Packaging_Form.xlsx

			Organ Labeling and Packaging
			Fields to be completed by members
			Form Section	Field Label	Notes
			Donor Setup-Donor Hospital	Hospital Name
			Donor Setup-Donor Hospital	City
			Donor Setup-Donor Hospital	State
			Donor Setup-Donor Hospital	Zip
			Donor Setup-Donor Hospital	Time Zone
			Donor Setup-Donor Hospital	DST Observed
			Donor Setup-Donor Info	Donor ID
			Donor Setup-Donor Info	ABO
			Donor Setup-Donor Info	Date of Birth
			Donor Setup-Donor Info	Donor Initials
			Donor Setup-Donor Info	Local ID
			Donor Setup-Donor Info	Verified Donor ID
			Donor Setup-Donor Info	Verified ABO
			Donor Setup-Donor Info	Verified Date of Birth
			Donor Setup-Donor Info	Verified Donor Initials
			Donor Setup-Donor Info	Verified Local ID
			Blood & Culture Labels-Blood Tubes With ABO	Draw Date
			Blood & Culture Labels-Blood Tubes With ABO	Draw Time
			Blood & Culture Labels-Blood Tubes With ABO	Initials
			Blood & Culture Labels-Blood Tubes With ABO	Comments
			Blood & Culture Labels-Blood Tubes Without ABO	Draw Date
			Blood & Culture Labels-Blood Tubes Without ABO	Draw Time
			Blood & Culture Labels-Blood Tubes Without ABO	Initials
			Blood & Culture Labels-Blood Tubes Without ABO	Comments
			Blood & Culture Labels-Cultures	Draw Date
			Blood & Culture Labels-Cultures	Draw Time
			Blood & Culture Labels-Cultures	Initials
			Blood & Culture Labels-Cultures	Type
			Blood & Culture Labels-Cultures	Site
			Infectious Disease Results	Anti-HBc
			Infectious Disease Results	Anti-HIV I/II
			Infectious Disease Results	HIV Ag/Ab Combo
			Infectious Disease Results	HIV NAT
			Infectious Disease Results	HBsAg
			Infectious Disease Results	HBV NAT
			Infectious Disease Results	Anti-HCV
			Infectious Disease Results	HCV NAT
			Infectious Disease Results	PHS Increased Risk Donor?
			Infectious Disease Results	Verified Anti-HBc
			Infectious Disease Results	Verified Anti-HIV I/II
			Infectious Disease Results	Verified HIV Ag/Ab Combo
			Infectious Disease Results	Verified HIV NAT
			Infectious Disease Results	Verified HBsAg
			Infectious Disease Results	Verified HBV NAT
			Infectious Disease Results	Verified Anti-HCV
			Infectious Disease Results	Verified HCV NAT
			Infectious Disease Results	Verified PHS Increased Risk Donor?
			Procurement Plan	Heart
			Procurement Plan	Left Lung
			Procurement Plan	Right Lung
			Procurement Plan	Lungs Enbloc
			Procurement Plan	Liver
			Procurement Plan	Liver Split Left
			Procurement Plan	Liver Split Right
			Procurement Plan	Pancreas
			Procurement Plan	Left Kidney
			Procurement Plan	Right Kidney
			Procurement Plan	Kidneys Enbloc
			Procurement Plan	Intestine
			Procurement	Date
			Procurement	Time
			Procurement – Organ Detail	Ice Date
			Procurement – Organ Detail	Ice Time
			Procurement – Organ Detail	Initials
			Procurement – Organ Detail	Ice Date 2
			Procurement – Organ Detail	Ice Time 2
			Procurement – Organ Detail	Initials 2
			Tissue/Extra Vessel Labels	Ice Date
			Tissue/Extra Vessel Labels	Ice Time
			Tissue/Extra Vessel Labels	Initials
			Tissue/Extra Vessel Labels	Ice Date 2
			Tissue/Extra Vessel Labels	Ice Time 2
			Tissue/Extra Vessel Labels	Initials 2
			VCA Packaging	Excision Date (Right)
			VCA Packaging	Excision Time (Right)
			VCA Packaging	Excision Date (Left)
			VCA Packaging	Excision Time (Left)
			VCA Packaging	Ice Date
			VCA Packaging	Ice Time
			VCA Packaging	Initials
			VCA Packaging	Ice Date 2
			VCA Packaging	Ice Time 2
			VCA Packaging	Initials 2
			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 0.27 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].