56 Kidney Paired Donation Donor Registration_Form_clean.xls

			Kidney Paired Donation Donor Registration
			Fields to be completed by members
			Form Section	Field Label	Notes
			Add a KPD Donor-Institution	Home transplant center
			Add a KPD Donor	Is this a non-directed donor?
			Add a KPD Donor	KPD candidate ID
			Add a KPD Donor	Donor name
			Add a KPD Donor	SSN
			Add a KPD Donor	Date of birth
			Add a KPD Donor	Donor status
			Add KPD Donor (Non-directed)	Home transplant center
			Add KPD Donor (Non-directed)	Is this a non-directed donor
			Add KPD Donor (Non-directed)	Donor name
			Add KPD Donor (Non-directed)	SSN
			Add KPD Donor (Non-directed)	Date of birth
			Add KPD Donor (Non-directed)	Donor status
			Donor Summary Details-Institution	Home transplant center	This field cannot be updated on this page.
			Donor Summary Details-Demographic Information	Last name
			Donor Summary Details-Demographic Information	First name
			Donor Summary Details-Demographic Information	Middle initial
			Donor Summary Details-Demographic Information	SSN
			Donor Summary Details-Demographic Information	Date of birth
			Donor Summary Details-Demographic Information	Current age
			Donor Summary Details-Demographic Information	Gender
			Donor Summary Details-Demographic Information	Center's patient ID
			Donor Summary Details-Demographic Information	State of permanent residence
			Donor Summary Details-Demographic Information	Permanent zip code
			Donor Summary Details-Demographic Information	Ethnicity
			Donor Summary Details-Demographic Information	Race
			Donor Summary Details-Clinical Information	ABO
			Donor Summary Details-Clinical Information	Height
			Donor Summary Details-Clinical Information	Weight
			Donor Summary Details-Clinical Information	BMI
			Donor Summary Details-KPD Information	Is this a non-directed donor?
			Donor Summary Details-KPD Information	Intended KPD Candidate ID
			Donor Summary Details-KPD Information	Candidate name	This field is read-only and only displays if the donor is a non-directed donor.
			Donor Summary Details-KPD Information	Donor's relationship to candidate
			Donor Summary Details-KPD Information	Are you willing to start a chain that continues with a bridge donor?
			Donor Summary Details-KPD Information	Does the donor have health insurance?
			Donor Summary Details-KPD Information	Has the donor signed the Agreement to participate in the KPD Pilot Program?
			Donor Summary Details-KPD Information	Has the donor signed a HIPAA form so that medical information may be shared?
			Donor Summary Details-KPD Information	Has the donor signed a living donor consent form as outlined in the KPD Operational Guidelines?
			Donor Summary Details-KPD Information	Has the donor undergone an evaluation as outlined in the KPD Operational Guidelines?
			Donor Summary Details-KPD Information	Has the donor had all age appropriate cancer screenings as defined by the American Cancer Society?
			Donor Summary Details-KPD Information	KPD status
			Donor Summary Details-KPD Information	Inactive reason
			Donor Summary Details-KPD Information	Other, specify
			Donor Summary Details-KPD Information	Specify
			Donor Summary Details-KPD Information	Removal reason
			Donor Summary Details-Comments	Comments
			Medical and Social History	Home transplant center	This field cannot be updated on this page.
			Medical and Social History	History of diabetes
			Medical and Social History	History of cancer
			Medical and Social History	Specify
			Medical and Social History	History of hypertension
			Medical and Social History	Compliant with treatment
			Medical and Social History	Number of medications for hypertension that the donor is on
			Medical and Social History	Please indicate the type of anti-hypertension medication and dosage
			Medical and Social History	Please indicate how long the donor has been on medication for hypertension
			Medical and Social History	History of coronary artery disease (CAD)
			Medical and Social History	Previous gastrointestinal disease
			Medical and Social History	Cigarette use (>20 pack years) ever
			Medical and Social History	Cigarette use continued in last 6 months
			Medical and Social History	Heavy alcohol use (2+ drinks/day)
			Medical and Social History	I.V. drug usage
			Medical and Social History	According to the OPTN policy currently in effect, does the donor have risk factors for blood-borne disease transmission?
			Medical and Social History	Abdominal trauma/surgery
			Medical and Social History	Number of arteries
			Medical and Social History	Number of veins
			Medical and Social History	Ureter
			Medical and Social History-Comments	Comments
			Vital Signs-Vital Signs	Home transplant center	This field cannot be updated on this page.
			Vital Signs-Vital Signs	Was 24-hour blood pressure monitor used?
			Vital Signs-Vital Signs	Blood pressure systolic (average of 24- hour period)	If YES is entered for Was 24-hour blood pressure monitor used
			Vital Signs-Vital Signs	Blood pressure diastolic (average of 24-hour period)	If YES is entered for Was 24-hour blood pressure monitor used
			Vital Signs-Vital Signs	Blood pressure date start (start of 24-hour period)	If YES is entered for Was 24-hour blood pressure monitor used
			Vital Signs-Vital Signs	Blood pressure systolic 1	If NO is entered for the Was a 24-hour blood pressure monitor used question
			Vital Signs-Vital Signs	Blood pressure diastolic 1	If NO is entered for the Was a 24-hour blood pressure monitor used question
			Vital Signs-Vital Signs	Blood pressure date 1	If NO is entered for the Was a 24-hour blood pressure monitor used question
			Vital Signs-Vital Signs	Blood pressure systolic 2	If NO is entered for the Was a 24-hour blood pressure monitor used question
			Vital Signs-Vital Signs	Blood pressure diastolic 2	If NO is entered for the Was a 24-hour blood pressure monitor used question
			Vital Signs-Vital Signs	Blood pressure date 2	If NO is entered for the Was a 24-hour blood pressure monitor used question
			Vital Signs-Vital Signs	Was a stress test performed?	If NO is entered for the Was a 24-hour blood pressure monitor used question
			Vital Signs-Comments	Comments
			Labs-Institution	Home transplant center	This field cannot be updated on this page
			Labs-Kidney Function	Date
			Labs-Kidney Function	Creatinine clearance (24 hours urine collection) (mL/min)
			Labs-Kidney Function	Date
			Labs-Kidney Function	GFR (isotopic method) (mL/min/1.73m2)
			Labs-Lab Values	HbA1c (%)
			Labs-Lab Values	Oral glucose tolerance test (OGTT)
			Labs-Lab Values	Method
			Labs-Lab Values	Date
			Labs-Lab Values	Microalbumin
			Labs-Lab Values	Urine protein-to-creatinine ratio
			Labs-Lab Values	24 hour urine protein
			Labs-Urinalysis	Date
			Labs-Urinalysis	Color
			Labs-Urinalysis	Appearance
			Labs-Urinalysis	pH
			Labs-Urinalysis	Specific gravity
			Labs-Urinalysis	Protein
			Labs-Urinalysis	Glucose
			Labs-Urinalysis	Blood
			Labs-Urinalysis	RBC
			Labs-Urinalysis	WBC
			Labs-Urinalysis	Epith (%)
			Labs-Urinalysis	Casts
			Labs-Urinalysis	Bacteria
			Labs-Urinalysis	Leukocyte esterase
			Labs-Lab Panel	Date
			Labs-Lab Panel	Na (mEq/L)
			Labs-Lab Panel	K+ (mmol/L)
			Labs-Lab Panel	Cl (mmol/L)
			Labs-Lab Panel	CO2 (mmol/L)
			Labs-Lab Panel	BUN (mg/dL)
			Labs-Lab Panel	Creatinine (mg/dL)
			Labs-Lab Panel	Glucose (mg/dL)
			Labs-Lab Panel	Total bilirubin (mg/dL)
			Labs-Lab Panel	Direct bilirubin (mg/dL)
			Labs-Lab Panel	Indirect bilirubin (mg/dL)
			Labs-Lab Panel	SGOT AST (u/L)
			Labs-Lab Panel	SGPT ALT (u/L)
			Labs-Lab Panel	Alkaline phosphatase (u/L)
			Labs-Lab Panel	GGT (u/L)
			Labs-Lab Panel	LDH (u/L)
			Labs-Lab Panel	Albumin (g/dL)
			Labs-Lab Panel	Total protein (g/dL)
			Labs-Lab Panel	Prothrombin (PT) (seconds)
			Labs-Lab Panel	INR
			Labs-Lab Panel	PTT (seconds)
			Labs-Lab Panel	Serum amylase (u/L)
			Labs-Lab Panel	Serum lipase (u/L)
			Labs-Complete Blood Count (CBC)	Date
			Labs-Complete Blood Count (CBC)	WBC (thous/mcL)
			Labs-Complete Blood Count (CBC)	RBC (mill/mcL)
			Labs-Complete Blood Count (CBC)	HgB (g/dL)
			Labs-Complete Blood Count (CBC)	Hct (%)
			Labs-Complete Blood Count (CBC)	Plt (thous/mcL)
			Labs-Complete Blood Count (CBC)	Bands (%)
			Labs-Comments	Comments
			Serologies	Anti-CMV
			Serologies	EBV (VCA) (IgG)
			Serologies	HBsAg
			Serologies	Anti-HBcAb
			Serologies	HBsAb
			Serologies	Anti-HCV
			Serologies	Anti-HIV I/II
			Serologies	Anti-HTLV I/II
			Serologies	RPR/VDRL
			Serologies	EBNA
			Serologies	EBV (VCA) (IgM)
			Serologies-Comments	Comments
			Tests and Attachments	Please select test or attachment
			Tests and Attachments-Add New Tests or Attachments	Test type
			Tests and Attachments-Add New Tests or Attachments	Diagnostic evaluation/comments
			Tests and Attachments-Add New Tests or Attachments	Attach medical image
			Tests and Attachments-Add New Tests or Attachments	Description
			Tests and Attachments-Add New Tests or Attachments	Select file	All fields in the Tests and Diagnoses table are read-only
			Tests and Attachments-Add New Tests or Attachments (Attachments)	Please select test or attachment
			Tests and Attachments-Add New Tests or Attachments (Attachments)	Description
			Tests and Attachments-Add New Tests or Attachments (Attachments)	Select File	All fields in the Attachments table are read-only
			Tests and Attachments-Delete Attachments	Reason deleted
			HLA-Institution	Home transplant center	This field cannot be updated on this page
			HLA-HLA Class I	A
			HLA-HLA Class I	A
			HLA-HLA Class I	B
			HLA-HLA Class I	B
			HLA-HLA Class I	BW4
			HLA-HLA Class I	BW6
			HLA-HLA Class I	C
			HLA-HLA Class I	C
			HLA-HLA Class II	DR
			HLA-HLA Class II	DR
			HLA-HLA Class II	DR51
			HLA-HLA Class II	DR51
			HLA-HLA Class II	DR52
			HLA-HLA Class II	DR52
			HLA-HLA Class II	DR53
			HLA-HLA Class II	DR53
			HLA-HLA Class II	DQB1
			HLA-HLA Class II	DQB1
			HLA-HLA Class II	DQA1
			HLA-HLA Class II	DQA1
			HLA-HLA Class II	DPB1
			HLA-HLA Class II	DPB1
			HLA-HLA Class II	DPA1
			HLA-HLA Class II	DPA1
			HLA-Comments	Comments
			Donor Choices-Institution	Home transplant center	This field cannot be updated on this page
			Donor Choices-KPD Donor Choices	Donor willing to travel?
			Donor Choices-KPD Donor Choices	If Yes, to which center(s) is the donor willing to travel?
			Donor Choices-KPD Donor Choices	Is the donor willing to have his or her kidney shipped?
			Donor Choices-KPD Donor Choices	This donor can ONLY donate his or her following kidney
			Donor Choices-KPD Donor Choices	Pair and center willing to participate in a 3-way match?
			Donor Choices-KPD Donor Choices	Pair and center willing to participate in a chain (not as a bridge donor)?
			Donor Choices-KPD Donor Choices	If matched with an opportunity to be a bridge donor, does the donor consent and the center agree to continue the chain as a bridge donor?
			Verify Donor ABO Subtype-Institution	Home transplant center	This field cannot be updated on this page
			Verify Donor ABO-Donor Information	Last name	This field is read-only
			Verify Donor ABO-Donor Information	First name	This field is read-only
			Verify Donor ABO-Donor Information	Middle initial	This field is read-only
			Verify Donor ABO-Donor Information	ABO
			Verify Donor ABO-Donor Information	Age	This field is read-only
			Verify Donor ABO-Donor Information	Gender	This field is read-only
			Verify Donor ABO-Donor Information	First user ABO entry	This field is read-only
			Verify Donor ABO Subtype-Institution	Home transplant center	This field cannot be updated on this page
			Verify Donor ABO Subtype-Donor Information	Last name	This field is read-only
			Verify Donor ABO Subtype-Donor Information	First name	This field is read-only
			Verify Donor ABO Subtype-Donor Information	Middle initial	This field is read-only
			Verify Donor ABO Subtype-Donor Information	ABO
			Verify Donor ABO Subtype-Donor Information	Age	This field is read-only
			Verify Donor ABO Subtype-Donor Information	Gender	This field is read-only
			Verify Donor ABO Subtype-Donor Information	First ABO subtype user	This field is read-only
			Manage Bridge Donors-Pending Bridge Donors	Select home transplant center
			Manage Bridge Donors-Pending Bridge Donors	KPD donor ID	This field is read-only
			Manage Bridge Donors-Pending Bridge Donors	Donor name	This field is read-only
			Manage Bridge Donors-Pending Bridge Donors	Match run date donor became a bridge donor	This field is read-only
			Manage Bridge Donors-Pending Bridge Donors	Bridge donor on hold	This field is optional
			Manage Bridge Donors-Pending Bridge Donors	Access bridge donor record
			Manage Bridge Donors-Pending Bridge Donors	Exchange number	This field is read-only
			Manage Bridge Donor Record	Home transplant center
			Manage Bridge Donor Record	KPD donor ID	This field is read-only
			Manage Bridge Donor Record	Donor name	This field is read-only
			Manage Bridge Donor Record	Bridge donor status
			Manage Bridge Donor Record	Bridge donor status date
			Manage Bridge Donor Record	Bridge donor on hold	This field is optional
			Manage Bridge Donor Record	KPD donor status	This field is read-only
			Manage Bridge Donor Record	Match run date donor became a bridge donor	This field is read-only
			Manage Bridge Donor Record	Exchange number	This field is read-only
			Manage Bridge Donor Record-Bridge donor status: Declined to donate reason	Bridge donor status declined to donate reasons
			Manage Bridge Donor Record-Bridge donor status: Declined to donate reason	Life circumstances have changed
			Manage Bridge Donor Record-Bridge donor status: Declined to donate reason	Medical condition has changed
			Manage Bridge Donor Record-Bridge donor status: Declined to donate reason	Other reasons
			Manage Bridge Donor Record-Bridge donor status: Declined to donate reason	Enter Comments
			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].