58 Disease Transmission Event_Form.xlsx

Data System for Organ Procurement and Transplantation Network

Disease Transmission Event_Form.xlsx

Disease Transmission Event

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf



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].








































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