54 Organ Tracking and Validating_Form.xlsx

			Organ Tracking and Validating
			Fields to be completed by members
			Form Section	Field Label	Notes
			Organ Check-In	Donor ID
			Organ Check-In	Organ
			Organ Check-In	ABO
			Organ Check-In	Facility Type
			Organ Check-In	Transplant Center
			Organ Check-In	Check-In Location
			Organ Check-In	Received By
			Organ Check-In	Comments
			Organ Check-In	Was this the expected Donor ID, organ, and laterality (if applicable)?
			Organ Re-ship	Donor ID
			Organ Re-ship	Organ
			Organ Re-ship	ABO
			Organ Re-ship	Current Facility Type
			Organ Re-ship	Reship by User Name
			Organ Re-ship	Where is the Organ Going?
			ABO Verification Document	First Anastomosis Time
			ABO Verification Document	Personnel Attesting to Visual Verification
			ABO Verification Document	Title of Personnel Attesting to Visual Verification
			ABO Verification Document	Transplant Surgeon Name
			ABO Verification Document	Transplant Surgeon Title
			ABO Verification Document	Licensed Health Professional Name
			ABO Verification Document	Licensed Health Professional Title
			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].