Potential disease transmissions become part of a confidential medical peer review process. The OPTN Ad Hoc Disease Transmission Advisory Committee (DTAC) examines individual potential disease transmission cases reported to the OPTN in an effort to confirm transmissions of donor origin whenever possible.
The initial report documents the OPO’s communication of the donor information to all transplant centers that utilized organs from the donor associated with the reported event. The report will be submitted for review by the DTAC. It is necessary to receive this document within 24 hours of the reported event into the Patient Safety System, in an effort to collect critical, time-sensitive information regarding the donor, organs, tissues, and extra vessels that were procured. The OPO should include all contact information for recipient center(s), tissue, and/or eye banks that have been notified of the potential for disease or malignancy transmission.
All fields on the initial report should be completed with the information available at the time of submission. It is acceptable that all information may not be available to submit within 24 hours of the report to the Patient Safety System.
Disease Transmission Event ID: The disease transmission event ID displays. You can find this ID within the Patient Safety Portal or Event Notification/Acknowledgment e-mail. This field is required.
Donor ID: Enter the seven-digit donor ID. This ID consists of letters and numbers. This field is required.
First
Name: Enter the first name of the person submitting
the form. Alphanumeric up to 50 characters. This field is
required.
Last
Name: Enter the last name of the person submitting the form.
Alphanumeric up to 50 characters. This field is required.
E-mail:
Enter the e-mail address of the person submitting the form.
Alphanumeric up to 80 characters. This field is required.
Phone: Enter the phone number of the person submitting the form. Alphanumeric up to 10 characters. This field is required.
The following suspected organism/disease(s) were reported: The suspected organism or disease reported displays in read-only format.
Additional
Comments: Enter additional information in the text
box. If recipients of organs or vessels are deceased prior to the
reported event, please also include this information in the comment
section on the report. Alphanumeric up to 10,000 characters.
As of today, the transmission is: Select the response from the drop-down list of options. This field is required. If required fields are not applicable to this case or if information is unknown, select Unknown in the answer field.
Suspected
Confirmed
Unknown
Date of Recovery: The date of recovery displays in read-only format.
Donor symptomatic prior to procurement?: This field is required.
Yes
No
Known at procurement?: This field is required.
Yes
No
Was an autopsy performed on the donor?: This field is required.
Yes
No
Unknown
Note:
If an autopsy was completed or will be performed on the donor, please
attach a copy to the event or email to the Patient Safety
Coordinators once it is completed.
What
type of donor specimen(s)/samples are available for further testing?:
Enter the type of donor specimen or samples that are available for
further testing. Alphanumeric up to 255 characters. This field is
required.
Was the donor blood sample obtained pre- or post-transfusion?: This field is required.
Pre-transfusion
Post-transfusion
N/A
If the sample was obtained post-transfusion, were hemodilution calculations performed?: This field is required.
Yes
No
Were all specimens saved for further testing (donor hospital, OPO, and TX Center)?: This field is required.
Yes
No
If blood specimens are available on the donor for testing, how much?: Enter the amount of blood specimens available for testing. Alphanumeric up to 255 characters. This field is required.
First Name: Enter the first name of the OPO contact. Alphanumeric up to 50 characters. This field is required.
Last Name: Enter the last name of the OPO contact. Alphanumeric up to 50 characters. This field is required.
Phone: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters. This field is required.
Other: Enter additional information. Alphanumeric up to 40 characters.
Have the public health authorities been contacted?:
Yes
No
If yes, complete the following fields:
First Name: Enter the first name of the public health authority contact. Alphanumeric up to 100 characters. This field is required.
Last Name: Enter the last name of the public health authority contact. This field is required.
Phone: Enter the phone number of the public health authority contact. Alphanumeric up to 10 characters. This field is required.
Phone Ext: Enter the phone number extension of the public health authority contact. Alphanumeric up to 50 characters.
Was an assay and/or other test used to identify organism/disease?: This field is required.
Yes
No
Unknown
If yes, complete the following fields:
Date of Test: Enter the date of the test. MM/DD/YYYY format.
Results: Select the response from the drop-down list of options. This field is required.
Positive
Negative
Indeterminate
Other
Assay/Test Type: This field is required.
Ab
Acid Fast Smear
Aerobic Cx
AFB Cx
BAL
Blood Cx
Bone Marrow Bx
Bronchial Bx
Bronchial Lavage
Bx
Cell block
Cell Ct & Diff
CMV stain,
CT of abd
CT of chest
CT of head
CT of pelvis
CXR
Cytology
DNA testing
FISH
Fluid Cx
Fungal Cx
Fungal stain
GMS stains
Gram stain
IgG
IgM
Legionella DFA & Cx
Molecular Fingerprinting
MRI of abd
MRI of chest
MRI of head
MRI of pelvis
NAT
PCR
Pneumocystis IFA
Pneumocystis stain
PPD
Silver stain
Smear
Sputum Cx
Surface antigen
Urinalysis
Urine Cx
US of abd
US of pelvis
Viral Cx
RNA
Other Specify
Note: If you need to add another Assay/Test, click on the Add Additional Assay/Tests link.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Heart: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: Select the radio button. This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Lung – Left: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Lung – Right: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Liver - Whole: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Liver – Segment 1: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Liver – Segment 2: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Intestine – Whole: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Intestine – Segment 1: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Intestine – Segment 2: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Pancreas – Whole: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Pancreas – Segment 1: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Pancreas – Segment 2: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Pancreas – Islet Cells: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Kidney – Right: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Organ/Vessels Recovered: This field is required.
Yes
No
If yes,
complete the following fields:
Kidney – Left: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Associated Vessels Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
N/A
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Abdominal Wall: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Head and Neck: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Upper Limb: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Lower Limb: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Musculoskeletal Composite Graft Segment: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Spleen: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Glands: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Genitourinary Organs: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Vascular composite allograft (VCA) recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
VCA – Other: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Discarded
Recovered for TX, but not TX
Recovered, but not TX
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Blood Vessels – Femoral: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Blood Vessels – Iliac: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Blood Vessels – Other: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Tissues – Bone: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Tissues – Fascia: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Tissues – Skin: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Tissues – Tendons: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Tissues – Heart Valves: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Tissues – Eyes/Corneas: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
Tissues recovered?: This field is required.
Yes
No
If yes,
complete the following fields:
Tissues – Tissue Other: This field is required.
Yes
No
If yes,
complete the following fields:
Organ Disposition: This field is required.
Transplanted
Stored
Quarantined
Discarded
Unknown
Contacted by OPO?: This field is required.
Yes
No
If yes,
complete the following fields:
Date
Contacted: Enter the date contacted by OPO. MM/DD/YYYY
format. This field is required.
Center
Name: Enter the center name. Alphanumeric up to 75
characters. This field is required.
Contact First Name: Enter the first name of the program contact. Alphanumeric up to 50 characters. This field is required.
Contact
Last Name: Enter the last name of the program contact.
Alphanumeric up to 50 characters. This field is required.
Contact
Email: Enter the email address of the program contact.
Alphanumeric up to 80 characters.
Contact Phone Number: Enter the phone number of the OPO contact. Alphanumeric up to 10 characters.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Potential Disease Transmission Report_Instructions |
| File Modified | 0000-00-00 |
| File Created | 2023-10-18 |