58 Disease Transmission Event_Form.xlsx

			Disease Transmission Event
			Fields to be completed by members
			Form Section	Field Label	Notes
			Event Information	Reporting Event for
			Event Information	Donor ID
			Event Information	Have all of the recipient centers been notified at this time?
			Event Information	Recipient SSN
			Event Information	Waitlist ID	Optional
			Event Information	Donor ID of donor involved
			Event Information	Has the Host OPO been notified regarding this report?
			Event Information	Reporting Institution
			Event Information	Detected by
			Event Information	Date Occurred
			Event Information	Infection/Malignancy/Other Medical Condition
			Add Infection	Specify Type
			Add Infection	Infection
			Add Infection	Date Detected
			Add Infection	At this time the diagnosis is
			Add Malignancy	Malignancy
			Add Malignancy	Date Detected
			Add Malignancy	At this time the diagnosis is
			Add Other Medical Condition	Other Medical Condition
			Add Other Medical Condition	Date Detected
			Add Other Medical Condition	At this time the diagnosis is
			Add Other Medical Condition	Please attach any relevant documents, including lab or diagnostic testing results: Choose File	Optional
			Add Other Medical Condition	Was an assay or other test used to identify organism disease?
			Add Assay/Test Type	Assay/Test Type
			Add Assay/Test Type	Results
			Add Assay/Test Type	Date of test
			Add Assay/Test Type	Was the donor blood sample obtained pre or post transfusion?
			Add Assay/Test Type	What donor specimens remain for further testing? (Please indicate type and amount)
			Add Assay/Test Type	Was tissue recovered from this donor?
			Add Assay/Test Type	Was an autopsy completed on this donor? (Please upload a copy of the autopsy report if available)
			Add Assay/Test Type	Have local/state public health authorities been contacted regarding this event? (If appropriate for nationally notifiable infectious diseases as defined by the US Public Health Services)
			Add Assay/Test Type	Enter narrative description of the event
			Contact Information	Who is the patient safety contact at your institution for this event? First Name
			Contact Information	Last Name
			Contact Information	Phone contact (enter at least one)
			Contact Information	Office
			Contact Information	ext.	Optional
			Contact Information	Pager/Beeper	Optional
			Contact Information	ext.	Optional
			Contact Information	Mobile	Optional
			Contact Information	ext.	Optional
			Contact Information	Email
			Contact Information	Other contact info	Optional
			Contact Information	ext.	Optional
			Contact Information	Person Submitting the Report
			Contact Information	First Name
			Contact Information	Last Name
			Contact Information	Email
			Contact Information	Submit
			Contact Information	Cancel
			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].