Living Donor Registration (LDR)

Data System for Organ Procurement and Transplantation Network

Living Donor Registration_Form_redline.xlsx

Living Donor Registration (LDR)

OMB: 0915-0157

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Living Donor Registration (LDR)
Fields to be completed by members




Form Section Field Label Notes
Provider Information Recipient Center Name Display Only
Provider Information Center Code Type Display Only - Cascades from Database
Provider Information Center Code Display Only - Cascades from Database
Donor Information Donor Last Name Display Only - Cascades from Database
Donor Information Donor First Name Display Only - Cascades from Database
Donor Information UNOS Donor ID # Display Only - Cascades from feedback
Donor Information Home Address
Donor Information Home City
Donor Information Home State
Donor Information Home Zip
Donor Information Home Phone
Donor Information Work Phone Not required
Donor Information Email Not required
Donor Information Donor SSN
Donor Information Donor Date of Birth
Donor Information Donor Gender//Gender
Donor Information Marital Status at Time of Donation
Donor Information ABO Blood Group Display Only - Cascades from Database
Donor Information Living Donor Type
Donor Information Living Donor Type Other Specify
Donor Information Ethnicity
Donor Information Select all origins that apply
Donor Information Ethnicity/Race
Donor Information Citizenship
Donor Information Year of Entry into U.S.
Donor Information Country of Permanent Residence
Donor Information Highest Education Level
Donor Information Did the donor have health insurance
Donor Information Functional Status
Donor Information Physical Capacity: (check one)
Donor Information Working for Income
Donor Information Working for Income//If No, Not Working Due To: (check one)
Donor Information Working for Income//If Yes
Donor Information % Macro vesicular fat
Donor Information % Micro vesicular fat
Pre-Donation Clinical Information Viral Detection://Have any of the following viruses ever been tested for: HIV, CMV, HBV, HCV, EBV
Pre-Donation Clinical Information HIV Status
Pre-Donation Clinical Information CMV Total Not required
Pre-Donation Clinical Information CMV//IgG
Pre-Donation Clinical Information CMV//IgM
Pre-Donation Clinical Information CMV//Nucleic Acid Testing Not required
Pre-Donation Clinical Information HBV
Pre-Donation Clinical Information HBV//Core Antibody
Pre-Donation Clinical Information HBV//Surface Antigen
Pre-Donation Clinical Information HBV//HBV/DNA (NAT/PCR)
Pre-Donation Clinical Information HCV
Pre-Donation Clinical Information HCV//Antibody
Pre-Donation Clinical Information HCV//RIBA
Pre-Donation Clinical Information HCV//HCV/RNA (NAT/PCR)
Pre-Donation Clinical Information EBV Total
Pre-Donation Clinical Information EBV//IgG
Pre-Donation Clinical Information EBV//IgM
Pre-Donation Clinical Information Pre-Donation//Height
Pre-Donation Clinical Information Pre-Donation Height//Status Value or status is reported, not both
Pre-Donation Clinical Information Pre-Donation//Weight
Pre-Donation Clinical Information Pre-Donation Weight//Status Value or status is reported, not both
Pre-Donation Clinical Information History of Cancer
Pre-Donation Clinical Information History of Cancer Specify//Specify Value or status is reported, not both
Pre-Donation Clinical Information Cancer Free Interval
Pre-Donation Clinical Information Cancer Free Interval //Status Value or status is reported, not both
Pre-Donation Clinical Information History of Cigarette Use
Pre-Donation Clinical Information History of Cigarette Use Pack Years//If Yes, Check # pack years
Pre-Donation Clinical Information Duration of Abstinence
Pre-Donation Clinical Information Other Tobacco Used Value or status is reported, not both
Pre-Donation Liver Clinical Information Total Bilirubin
Pre-Donation Liver Clinical Information Total Bilirubin//Status Value or status is reported, not both
Pre-Donation Liver Clinical Information SGOT/AST
Pre-Donation Liver Clinical Information SGOT/AST//Status Value or status is reported, not both
Pre-Donation Liver Clinical Information SGPT/ALT
Pre-Donation Liver Clinical Information SGPT/ALT//Status Value or status is reported, not both
Pre-Donation Liver Clinical Information Alkaline Phosphatase
Pre-Donation Liver Clinical Information Alkaline Phosphatase//Status Value or status is reported, not both
Pre-Donation Liver Clinical Information Serum Albumin
Pre-Donation Liver Clinical Information Serum Albumin//Status Value or status is reported, not both
Pre-Donation Liver Clinical Information Serum Creatinine
Pre-Donation Liver Clinical Information Serum Creatinine//Status Value or status is reported, not both
Pre-Donation Liver Clinical Information INR
Pre-Donation Liver Clinical Information INR//Status Value or status is reported, not both
Pre-Donation Liver Clinical Information Liver Biopsy
Pre-Donation Liver Clinical Information % Macro/intermediate vesicular fat //Status Value or status is reported, not both
Pre-Donation Liver Clinical Information % Micro/intermediate vesicular fat //Status Value or status is reported, not both
Pre-Donation Kidney Clinical Information History of Hypertension
Pre-Donation Kidney Clinical Information History of Hypertension Diet
Pre-Donation Kidney Clinical Information History of Hypertension Diuretics Display Only - Cascades from Database
Pre-Donation Kidney Clinical Information History of Hypertension Other Hypertensive Medication
Pre-Donation Kidney Clinical Information Diabetes
Pre-Donation Kidney Clinical Information Diabetes Treatment
Pre-Donation Kidney Clinical Information Kidney Preoperative Creatinine//Serum Creatinine
Pre-Donation Kidney Clinical Information Kidney Preoperative Creatinine//Status Value or status is reported, not both
Pre-Donation Kidney Clinical Information Preoperative Blood Pressure Systolic
Pre-Donation Kidney Clinical Information Preoperative Blood Pressure Systolic//Status Value or status is reported, not both
Pre-Donation Kidney Clinical Information Preoperative Blood Pressure Diastolic
Pre-Donation Kidney Clinical Information Preoperative Blood Pressure Diastolic//Status Value or status is reported, not both
Pre-Donation Kidney Clinical Information Urinalysis Display Only
Pre-Donation Kidney Clinical Information Preoperative Urinalysis//Urine Protein Value or status is reported, not both
Pre-Donation Kidney Clinical Information Preoperative Urinalysis//Protein-Creatinine Ratio
Pre-Donation Lung Clinical Information Diabetes
Pre-Donation Lung Clinical Information Diabetes Treatment
Pre-Donation Lung Clinical Information FVC % predicted before//FVC % predicted Value or status is reported, not both
Pre-Donation Lung Clinical Information FVC % predicted before//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information FVC % predicted after//FVC % predicted Value or status is reported, not both
Pre-Donation Lung Clinical Information FVC % predicted after//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information FEV1 % predicted before//FEV1 % predicted
Pre-Donation Lung Clinical Information FEV1 % predicted before//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information FEV1 % predicted after//FEV1 % predicted
Pre-Donation Lung Clinical Information FEV1 % predicted after//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information FEF (25-75%) % predicted before//FEF (25-75%) % predicted
Pre-Donation Lung Clinical Information FEF (25-75%) % predicted before//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information FEF (25-75%) % predicted after//FEF (25-75%) % predicted
Pre-Donation Lung Clinical Information FEF (25-75%) % predicted after//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information TLC % predicted before//TLC % predicted
Pre-Donation Lung Clinical Information TLC % predicted before//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information TLC % predicted after//TLC % predicted
Pre-Donation Lung Clinical Information TLC % predicted after//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information Diffusing lung capacity corrected for alveolar volume % predicted
Pre-Donation Lung Clinical Information Diffusing lung capacity corrected for alveolar volume % predicted//Status Value or status is reported, not both
Pre-Donation Lung Clinical Information PaO2 on room air
Pre-Donation Lung Clinical Information PaO2 on room air//Status Value or status is reported, not both
Pre-Donation All VCA Clinical Information Toxoplasma IgG
Pre-Donation Uterus Clinical Information Human Papillomavirus (HPV) - cervical specimen only by DNA or mRNA
Pre-Donation Uterus Clinical Information Herpes Simplex Virus (HSV) 1/2 (IgG)
Pre-Donation Uterus Clinical Information Gonorrhea (NAT)
Pre-Donation Uterus Clinical Information Gonorrhea (NAT)//If positive, was the patient treated?
Pre-Donation Uterus Clinical Information Chlamydia (NAT)
Pre-Donation Uterus Clinical Information Chlamydia (NAT)//If positive, was the patient treated?
Pre-Donation Uterus Clinical Information Vaginal Candidiasis (collected at the time of evaluation)
Pre-Donation Uterus Clinical Information Vaginal Candidiasis (collected at the time of evaluation)//If positive, was the patient treated?
Pre-Donation Uterus Clinical Information Vaginal Candidiasis (collected at the time of donation)
Pre-Donation Uterus Clinical Information Vaginal Candidiasis (collected at the time of donation)//If positive, was the patient treated?
Pre-Donation Uterus Clinical Information Bacterial Vaginosis (Gardnerella vaginalis)
Pre-Donation Uterus Clinical Information Bacterial Vaginosis (Gardnerella vaginalis)//If positive, was the patient treated?
Pre-Donation Uterus Clinical Information Trichomoniasis
Pre-Donation Uterus Clinical Information Trichomoniasis//If positive, was the patient treated?
Pre-Donation Uterus Clinical Information Other testing - specify
Pre-Donation Uterus Clinical Information Other testing - specify//Result
Pre-Donation Uterus Clinical Information Uterine Imaging Conducted (select all that apply)
Pre-Donation Uterus Clinical Information Uterine Imaging Conducted (select all that apply)//If Other, Specify
Pre-Donation Uterus Clinical Information Uterine Imaging Conducted (select all that apply)//If imaging was conducted, indicate any abnormal findings Display only
Pre-Donation Uterus Clinical Information Uterine Imaging Conducted (select all that apply)//If imaging was conducted, indicate any abnormal findings//MRI/MRA
Pre-Donation Uterus Clinical Information Uterine Imaging Conducted (select all that apply)//If imaging was conducted, indicate any abnormal findings//CT
Pre-Donation Uterus Clinical Information Uterine Imaging Conducted (select all that apply)//If imaging was conducted, indicate any abnormal findings//Other
Pre-Donation Uterus Clinical Information Gravidity
Pre-Donation Uterus Clinical Information Parity
Pre-Donation Uterus Clinical Information Spontaneous Abortion
Pre-Donation Uterus Clinical Information Induced Termination
Pre-Donation Uterus Clinical Information Prior Full Term Live Births
Pre-Donation Uterus Clinical Information Prior Full Term Live Births//If yes, indicate type of delivery for all prior births Display only
Pre-Donation Uterus Clinical Information Prior Full Term Live Births//If yes, indicate type of delivery for all prior births//Total number of births
Pre-Donation Uterus Clinical Information Prior Full Term Live Births//If yes, indicate type of delivery for all prior births//Number of vaginal deliveries
Pre-Donation Uterus Clinical Information Prior Full Term Live Births//If yes, indicate type of delivery for all prior births//Number of deliveries by C-section
Liver Surgical Information Type of Transplant Graft
Kidney Surgical Information Kidney//Type of Transplant Graft Display Only - Cascades from Database
Kidney Surgical Information Kidney//Intended Procedure Type Value or status is reported, not both
Kidney Surgical Information Conversion from Laparoscopic to Open
Lung Surgical Information Lung//Type of Transplant Graft Display Only - Cascades from Database
Lung Surgical Information Lung//Procedure Type Value or status is reported, not both
Lung Surgical Information Conversion from Thoracoscopic to Open
Lung Surgical Information Intra-operative Complications
Lung Surgical Information Intra-operative Complications Specify//If Yes, Specify
Lung Surgical Information Sacrifice of Second Lobe, Specify
Lung Surgical Information Anesthetic Complication Specify
Lung Surgical Information Arrhythmia requiring therapy
Lung Surgical Information Intra-operative Complications Other//Other Specify
Uterus Surgical Information Intended Procedure Type
Uterus Surgical Information Intended Procedure Type//If Robotic, was there a conversion from Robotic to Open?
Uterus Surgical Information Operative Time (surgical time from skin to skin) Display only
Uterus Surgical Information Operative Time (surgical time from skin to skin)//Start time
Uterus Surgical Information Operative Time (surgical time from skin to skin)//End time
Uterus Surgical Information Ovaries removed?
Uterus Surgical Information Intra-Operative Complications
Uterus Surgical Information Intra-Operative Complications//If yes, select all that occurred
Uterus Surgical Information Intra-Operative Complications//If yes, select all that occurred//If Ureter injury, which occurred?
Uterus Surgical Information Intra-Operative Complications//If yes, select all that occurred//If Ureter injury, which occurred//Was injury corrected?
Uterus Surgical Information Intra-Operative Complications//If yes, select all that occurred//If Anesthetic complication, specify
Uterus Surgical Information Intra-Operative Complications//If yes, select all that occurred//If Other, specify
Other VCA Surgical Information Intra-Operative Complications
Other VCA Surgical Information Intra-Operative Complications//If yes, select all that occurred
Other VCA Surgical Information Intra-Operative Complications//If yes, select all that occurred//If Anesthetic complication, specify
Other VCA Surgical Information Intra-Operative Complications//If yes, select all that occurred//If Other, specify
Post-Operative Information Date of Initial Discharge
Post-Operative Information Donor Status
Post-Operative Information Date Last Seen or Death
Post-Operative Information Cause of Death
Post-Operative Information Cause of Death//Other Specify
Post-Operative Information Non-Autologous Blood Administration
Post-Operative Information PRBC Units//If Yes, Number of Units
Post-Operative Information Platelets Units//If Yes, Number of Units
Post-Operative Information FF Units//If Yes, Number of Units
Uterus Post-Operative Information Length of ICU Stay (days)
Liver Related Post-Operative Complications Biliary Complications
Liver Related Post-Operative Complications Biliary Complications//If Yes, Specify
Liver Related Post-Operative Complications Biliary Complications//If Yes, Specify://Date of surgery
Liver Related Post-Operative Complications Liver Vascular Complications Requiring Intervention//Vascular Complications Requiring Intervention
Liver Related Post-Operative Complications Liver Vascular Complications//If Yes, Specify
Liver Related Post-Operative Complications Liver Vascular Complications Other//Specify
Liver Related Post-Operative Complications Liver Other Complications Requiring Intervention
Liver Related Post-Operative Complications Liver Other Complications//If Yes, Specify
Liver Related Post-Operative Complications Liver Other Complications Other//Specify
Liver Related Post-Operative Complications Liver Reoperation
Liver Related Post-Operative Complications Reoperation//If yes, specify reason for reoperation (during first six weeks)
Liver Related Post-Operative Complications Liver Reoperation Liver Failure
Liver Related Post-Operative Complications Liver Reoperation Liver Failure Date
Liver Related Post-Operative Complications Liver Reoperation Bleeding Complications
Liver Related Post-Operative Complications Liver Reoperation Bleeding Date//Date
Liver Related Post-Operative Complications Liver Reoperation Hernia Repair
Liver Related Post-Operative Complications Liver Reoperation Hernia Repair Date
Liver Related Post-Operative Complications Liver Reoperation Bowel Obstruction
Liver Related Post-Operative Complications Liver Reoperation Bowel Obstruction Date
Liver Related Post-Operative Complications Liver Reoperation Vascular Complications
Liver Related Post-Operative Complications Liver Reoperation Vascular Date
Liver Related Post-Operative Complications Liver Reoperation Other//Other Specify
Liver Related Post-Operative Complications Liver Reoperation Other Specify//Other Specify
Liver Related Post-Operative Complications Liver Reoperation Other Date
Liver Related Post-Operative Complications Liver Readmission//Any Readmission After Initial Discharge
Liver Related Post-Operative Complications Liver Readmission Reason//If yes, specify reason for readmission (during first six weeks)
Liver Related Post-Operative Complications Liver Readmission Reason Other//Other Specify
Liver Related Post-Operative Complications Liver Readmission Date//If Yes, Date of First Readmission
Liver Related Post-Operative Complications Liver Other Interventional Procedures
Liver Related Post-Operative Complications Liver Other Interventional Procedures//If Yes, Specify Procedure
Liver Related Post-Operative Complications Liver Other Interventional Procedures Date//Date of Procedure
Kidney Related Post-Operative Complications Kidney Vascular Complications Requiring Intervention//Vascular Complications Requiring Intervention
Kidney Related Post-Operative Complications Kidney Vascular Complications//If Yes, Specify
Kidney Related Post-Operative Complications Kidney Vascular Complications Other//Specify
Kidney Related Post-Operative Complications Kidney Other Complications Requiring Intervention//Other Complications Requiring Intervention
Kidney Related Post-Operative Complications Kidney Other Complications//If Yes, Specify
Kidney Related Post-Operative Complications Kidney Other Complications Other//Other Specify
Kidney Related Post-Operative Complications Kidney Reoperation//Reoperation
Kidney Related Post-Operative Complications Reoperation//If yes, specify reason for reoperation (during first six weeks)
Kidney Related Post-Operative Complications Kidney Reoperation Bleeding//Bleeding
Kidney Related Post-Operative Complications Kidney Reoperation Bleeding Date//Date
Kidney Related Post-Operative Complications Kidney Reoperation Hernia Repair//Hernia Repair
Kidney Related Post-Operative Complications Kidney Reoperation Hernia Repair Date//Date
Kidney Related Post-Operative Complications Kidney Reoperation Bowel Obstruction//Bowel Obstruction
Kidney Related Post-Operative Complications Kidney Reoperation Bowel Obstruction Date//Date
Kidney Related Post-Operative Complications Kidney Reoperation Vascular//Vascular
Kidney Related Post-Operative Complications Kidney Reoperation Vascular Date//Date
Kidney Related Post-Operative Complications Kidney Reoperation Other//Other Specify
Kidney Related Post-Operative Complications Kidney Reoperation Other Specify//Other Specify
Kidney Related Post-Operative Complications Kidney Reoperation Other Date//Date
Kidney Related Post-Operative Complications Kidney Readmission//Any Readmission After Initial Discharge
Kidney Related Post-Operative Complications Kidney Readmission Reason//If yes, specify reason for readmission (during first six weeks)
Kidney Related Post-Operative Complications Kidney Readmission Reason Other//Other Specify
Kidney Related Post-Operative Complications Kidney Readmission Date//If Yes, Date of First Readmission
Kidney Related Post-Operative Complications Kidney Other Interventional Procedures//Other Interventional Procedures
Kidney Related Post-Operative Complications Kidney Other Interventional Procedures//If Yes, Specify Procedure
Kidney Related Post-Operative Complications Kidney Other Interventional Procedures Date//Date of Procedure
Liver Related Post-Operative Complications Lung Readmission Reason Other//Specify
Liver Related Post-Operative Complications Post-operative complications during the initial hospitalization
Liver Related Post-Operative Complications Post-operative Complications//If Yes, Specify
Liver Related Post-Operative Complications Arrhythmia requiring therapy
Liver Related Post-Operative Complications Placement of Additional Thoracostomy Tube(s), Indication
Liver Related Post-Operative Complications Post-operative Complications Other//Other Specify
Liver Related Post-Operative Complications Lung Readmission//Any Readmission After Initial Discharge
Lung Related Post-Operative Complications Lung Readmission Reason//If yes, specify reason for readmission (during first six weeks)
Liver Related Post-Operative Complications Lung Readmission Reason Other//Specify
Lung Related Post-Operative Complications Lung Readmission Date//If Yes, Date of First Readmission
Uterus Related Post-Operative Complications Post-Operative Complications
Uterus Related Post-Operative Complications Post-Operative Complications//If yes, select all that apply
Uterus Related Post-Operative Complications Post-Operative Complications//If yes, select all that apply//Other - specify
Other VCA Related Post-Operative Complications Post-Operative Complications
Other VCA Related Post-Operative Complications Post-Operative Complications//If yes, specify complication
All VCA Related Post-Operative Complications Reoperation
All VCA Related Post-Operative Complications Reoperation//If yes, specify reason for reoperation (during first six weeks)
All VCA Related Post-Operative Complications Reoperation//If yes, specify reason for reoperation (during first six weeks)//Date
Post-Operative Clinical Information Most Recent Date of Tests
Post-Operative Clinical Information Weight in lb.
Post-Operative Clinical Information Kidney Serum Creatinine
Post-Operative Clinical Information Kidney Serum Creatinine//Status Value or status is reported, not both
Post-Operative Clinical Information Post-Op Blood Pressure Systolic
Post-Operative Clinical Information Post-Op Blood Pressure Systolic//Status Value or status is reported, not both
Post-Operative Clinical Information Post-Op Blood Pressure Diastolic
Post-Operative Clinical Information Post-Op Blood Pressure Diastolic//Status Value or status is reported, not both
Post-Operative Clinical Information Urinalysis Display Only
Post-Operative Clinical Information Post-Operative Urinalysis//Urine Protein Value or status is reported, not both
Post-Operative Clinical Information Post-Operative Urinalysis//Protein-Creatinine Ratio
Post-Operative Clinical Information Donor Developed Hypertension Requiring Medication
Post-Operative Clinical Information Total Bilirubin Value or status is reported, not both
Post-Operative Clinical Information Total Bilirubin//Status Value or status is reported, not both
Post-Operative Clinical Information SGOT/AST
Post-Operative Clinical Information SGOT/AST//Status Value or status is reported, not both
Post-Operative Clinical Information SGPT/ALT
Post-Operative Clinical Information SGPT/ALT//Status Value or status is reported, not both
Post-Operative Clinical Information Alkaline Phosphatase
Post-Operative Clinical Information Alkaline Phosphatase//Status Value or status is reported, not both
Post-Operative Clinical Information Serum Albumin
Post-Operative Clinical Information Serum Albumin//Status Value or status is reported, not both
Post-Operative Clinical Information Serum Creatinine
Post-Operative Clinical Information Serum Creatinine//Status Value or status is reported, not both
Post-Operative Clinical Information INR
Post-Operative Clinical Information INR//Status Value or status is reported, not both
Post-Operative Clinical Information Post-Operative//Weight
Post-Operative Clinical Information Post-Operative Weight//Status Value or status is reported, not both
Post-Operative Clinical Information Organ Recovery Date
Post-Operative Clinical Information Organ(s) Recovered Value or status is reported, not both
Post-Operative Clinical Information Recipient Last Name
Post-Operative Clinical Information Recipient First Name Value or status is reported, not both
Post-Operative Clinical Information Recipient SSN#
Post-Operative Clinical Information Donor Recovery Facility Center Code//Donor Recovery Facility Display Only - Cascades from Database
Post-Operative Clinical Information Donor Recovery Facility Center Type Display Only - Cascades from Database
Post-Operative Clinical Information Donor Workup Facility Center Code Display Only - Cascades from Database
Post-Operative Clinical Information Donor Workup Facility Center Type Display Only - Cascades from Database









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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