Recipient Histocompatibility Form

			Recipient Histocompatibility Form
			Fields to be completed by members
			Form Section	Field Label	Notes
			Provider Information	Lab Center Code//Lab:	Display Only - Cascades from Database
			Provider Information	Lab Center Type//Lab:	Display Only - Cascades from Database
			Provider Information	Lab Name//Lab	Display Only - Cascades from Database
			Provider Information	Transplant Center Code	Display Only - Cascades from Database
			Provider Information	Transplant Center Type	Display Only - Cascades from Database
			Provider Information	Tx Center Name	Display Only - Cascades from Database
			Recipient Information	Recipient Last Name	Display Only - Cascades from TCR
			Recipient Information	Recipient First Name	Display Only - Cascades from TCR
			Recipient Information	Recipient Middle Int	Display Only - Cascades from Database
			Recipient Information	Transplant Date	Display Only - Cascades from Database
			Recipient Information	SSN	Display Only - Cascades from TCR
			Recipient Information	HIC	Display Only - Cascades from TCR
			Recipient Information	Organ(s)	Display Only - Cascades from Database
			Recipient Information	DOB	Display Only - Cascades from Database
			Recipient Information	Gender	Display Only - Cascades from Database
			Recipient Information	Most Recent CPRA	Display Only - Cascades from Database
			Recipient Information	Peak CPRA	Display Only - Cascades from Database
			Recipient Information	Unacceptable Antigens	Display Only - Cascades from Database
			Donor Information	UNOS Donor ID#	Display Only - Cascades from feedback
			Donor Information	Donor Type	Display Only - Cascades from feedback
			Test Information	HLA Typing Done
			Test Information	HLA Antibody Screening Done
			Test Information	Crossmatch Done
			Test Information	If yes, was the crossmatch prospective to transplant
			Test Information	Donor Retyped at Your Center
			Recipient HLA Typing	Date Typing Completed Class I
			Recipient HLA Typing	Typing Method Class I
			Recipient HLA Typing	A
			Recipient HLA Typing	A
			Recipient HLA Typing	B
			Recipient HLA Typing	B
			Recipient HLA Typing	Bw4
			Recipient HLA Typing	Bw6
			Recipient HLA Typing	Cw
			Recipient HLA Typing	Cw
			Recipient HLA Typing	Date Typing Completed Class II
			Recipient HLA Typing	Typing Method Class II
			Recipient HLA Typing	DR
			Recipient HLA Typing	DR
			Recipient HLA Typing	DR51
			Recipient HLA Typing	DR51
			Recipient HLA Typing	DR52
			Recipient HLA Typing	DR52
			Recipient HLA Typing	DR53
			Recipient HLA Typing	DR53
			Recipient HLA Typing	DQB
			Recipient HLA Typing	DQB
			Recipient HLA Typing	DQA
			Recipient HLA Typing	DQA
			Recipient HLA Typing	DPB
			Recipient HLA Typing	DPB
			Recipient HLA Typing	DPA
			Recipient HLA Typing	DPA
			HLA Antibody Screening	Cytotoxicity:
			HLA Antibody Screening	Solid Phase:
			HLA Antibody Screening	Was there current donor specific HLA antibody?
			HLA Antibody Screening	Was there historical donor specific HLA antibody?
			HLA Antibody Screening	CPRA (%) - Most Recent
			HLA Antibody Screening	CPRA (%) - Most Recent//Status	Value or status is reported, not both
			HLA Antibody Screening	CPRA (%) - Peak
			HLA Antibody Screening	CPRA (%) - Peak//Status	Value or status is reported, not both
			Crossmatch	Date of most the recent crossmatch serum:
			Crossmatch	Cell Source:
			Crossmatch	Which T-cell crossmatch tests were performed?
			Crossmatch	Crossmatch Done//Which T-cell crossmatch tests were preformed?//T-cell Result:
			Crossmatch	Crossmatch Done//Which T-cell crossmatch tests were preformed?//T-cell Result:
			Crossmatch	Crossmatch Done//Which T-cell crossmatch tests were preformed?//T-cell Result:
			Crossmatch	Crossmatch Done//Which T-cell crossmatch tests were preformed?//T-cell Result:
			Crossmatch	Which B-cell crossmatch tests were performed?
			Crossmatch	Crossmatch Done//Which B-cell crossmatch tests were preformed?//B-cell Result:
			Crossmatch	Crossmatch Done//Which B-cell crossmatch tests were preformed?//B-cell Result:
			Crossmatch	Crossmatch Done//Which B-cell crossmatch tests were preformed?//B-cell Result:
			Crossmatch	Crossmatch Done//Which B-cell crossmatch tests were preformed?//B-cell Result:
			Crossmatch	Which historical crossmatch tests were performed?
			Crossmatch	Crossmatch Done//Which historical crossmatch tests were preformed?//Historical Result:
			Crossmatch	Crossmatch Done//Which historical crossmatch tests were preformed?//Historical Result:
			Crossmatch	Crossmatch Done//Which historical crossmatch tests were preformed?//Historical Result:
			Crossmatch	Crossmatch Done//Which historical crossmatch tests were preformed?//Historical Result:
			Donor Retyping	Donor Retyped Class I
			Donor Retyping	A	Display Only - Cascades from Database
			Donor Retyping	A	Display Only - Cascades from Database
			Donor Retyping	B	Display Only - Cascades from Database
			Donor Retyping	B	Display Only - Cascades from Database
			Donor Retyping	Bw4	Display Only - Cascades from Database
			Donor Retyping	Bw6	Display Only - Cascades from Database
			Donor Retyping	Cw	Display Only - Cascades from Database
			Donor Retyping	Cw	Display Only - Cascades from Database
			Donor Retyping	Date Typing Completed Class I
			Donor Retyping	Typing Method Class I
			Donor Retyping	A
			Donor Retyping	A
			Donor Retyping	B
			Donor Retyping	B
			Donor Retyping	Bw4
			Donor Retyping	Bw6
			Donor Retyping	Cw
			Donor Retyping	Cw
			Donor Retyping	Donor Retyped Class II
			Donor Retyping	DR	Display Only - Cascades from Database
			Donor Retyping	DR	Display Only - Cascades from Database
			Donor Retyping	DR51	Display Only - Cascades from Database
			Donor Retyping	DR51	Display Only - Cascades from Database
			Donor Retyping	DR52	Display Only - Cascades from Database
			Donor Retyping	DR52	Display Only - Cascades from Database
			Donor Retyping	DR53	Display Only - Cascades from Database
			Donor Retyping	DR53	Display Only - Cascades from Database
			Donor Retyping	DQB	Display Only - Cascades from Database
			Donor Retyping	DQB	Display Only - Cascades from Database
			Donor Retyping	DQA	Display Only - Cascades from Database
			Donor Retyping	DQA	Display Only - Cascades from Database
			Donor Retyping	DPB	Display Only - Cascades from Database
			Donor Retyping	DPB	Display Only - Cascades from Database
			Donor Retyping	DPA	Display Only - Cascades from Database
			Donor Retyping	DPA	Display Only - Cascades from Database
			Donor Retyping	Date Typing Completed Class II
			Donor Retyping	Typing Method Class II
			Donor Retyping	DR
			Donor Retyping	DR
			Donor Retyping	DR51
			Donor Retyping	DR51
			Donor Retyping	DR52
			Donor Retyping	DR52
			Donor Retyping	DR53
			Donor Retyping	DR53
			Donor Retyping	DQB
			Donor Retyping	DQB
			Donor Retyping	DQA
			Donor Retyping	DQA
			Donor Retyping	DPB
			Donor Retyping	DPB
			Donor Retyping	DPA
			Donor Retyping	DPA
			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].