Kidney Paired Donation Candidate Registration_Form_redline.xlsx

			Kidney Paired Donation Candidate Registration
			Fields to be completed by members
			Form Section	Field Label	Notes
			Add a KPD Candidate	Institution: Home transplant center
			Add a KPD Candidate	SSN
			Add a KPD Candidate	Date of birth
			Add a KPD Candidate	Waitlist ID
			Candidate Summary Details Institution	Home transplant center	This field cannot be updated on this page
			Candidate Summary Details Demographic Information	Last name	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	First name	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	Middle initial	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	SSN	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	Date of birth	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	Current age	This field cannot be updated on this page
			Candidate Summary Details Demographic Information	Gender	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	Center's patient ID	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	State of permanent residence	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	Permanent zip code	This field is copied from the candidate’s Waitlist registration
			Candidate Summary Details Demographic Information	Ethnicity
			Candidate Summary Details Demographic Information	Select all origins that apply
			Candidate Summary Details Demographic Information	Ethnicity/race
			Candidate Details Clinical Information	ABO	If the KPD candidate has an existing record in Waitlist, the KPD candidate's ABO blood type is copied from Waitlist
			Candidate Details Clinical Information	Height	If the KPD candidate has an existing record in Waitlist, the KPD candidate's height is copied from Waitlist
			Candidate Details Clinical Information	Weight	If the KPD candidate has an existing record in Waitlist, the KPD candidate's weight is copied from Waitlist
			Candidate Details Clinical Information	BMI	This field cannot be updated
			Candidate Details Clinical Information	CPRA	The KPD candidate's CPRA displays based on information entered in Waitlist. This field cannot be updated
			Candidate Details Clinical Information	Is candidate currently on dialysis?	The answer to this question displays based on information entered in Waitlist. This field cannot be updated
			Candidate Details Clinical Information	Dialysis date	The answer to this question displays based on information entered in Waitlist. This field cannot be updated
			Candidate Details KPD Information	Has the candidate signed the Agreement to participate in the KPD Pilot Program?
			Candidate Details KPD Information	Has the candidate signed to release protected health information so that medical information may be shared with other transplant hospitals?
			Candidate Details KPD Information	Is the candidate a prior living donor?
			Candidate Details KPD Information	KPD waiting time start date
			Candidate Details KPD Information	Is the candidate considered a pediatric candidate in the KPD system?	This field cannot be updated on this page
			Candidate Details KPD Information	Orphaned candidate	This field cannot be updated
			Candidate Details KPD Information	KPD status
			Candidate Details KPD Information	Inactive reason
			Candidate Details KPD Information	Other, Specify
			Candidate Details KPD Information	Removal reason
			Candidate Details KPD Information	Other, Specify
			Candidate Details Comments	Comments
			Candidate Choices Institution	Home transplant center	This field cannot be updated on this page
			Candidate Choices KPD Candidate Choices	Candidate willing to travel?
			Candidate Choices KPD Candidate Choices	If so, to which center(s) is the candidate willing to travel?
			Candidate Choices KPD Candidate Choices	Would candidate be willing to travel further if funding were provided?
			Candidate Choices KPD Candidate Choices	Will candidate accept a shipped kidney?
			Candidate Choices KPD Candidate Choices	If yes, from which centers is the candidate willing to accept a shipped kidney?
			Candidate Choices KPD Candidate Choices	Minimum acceptable donor age
			Candidate Choices KPD Candidate Choices	Maximum acceptable donor age
			Candidate Choices KPD Candidate Choices	Minimum acceptable donor BMI
			Candidate Choices KPD Candidate Choices	Minimum acceptable donor creatinine clearance (24-hour urine collection) or donor GFR (isotopic method)
			Candidate Choices KPD Candidate Choices	Maximum acceptable donor blood pressure – systolic (average)
			Candidate Choices KPD Candidate Choices	Maximum acceptable donor blood pressure - diastolic (average)
			Candidate Choices KPD Candidate Choices	Candidate willing to accept a donor who is Hep B core antibody positive?* *Assumes donor is Hep B surface antigen negative
			Candidate Choices KPD Candidate Choices	Candidate willing to accept a CMV positive donor?
			Candidate Choices KPD Candidate Choices	Candidate willing to accept an EBV positive donor?
			Candidate Choices KPD Candidate Choices	Candidate willing to accept only left kidney, only right kidney, or either kidney?
			HLA and Unacceptables Institution	Home transplant center	This field cannot be updated on this page
			HLA and Unacceptables Class I	A
			HLA and Unacceptables Class I	A
			HLA and Unacceptables Class I	B
			HLA and Unacceptables Class I	B
			HLA and Unacceptables Class I	BW4
			HLA and Unacceptables Class I	BW6
			HLA and Unacceptables Class I	C
			HLA and Unacceptables Class I	C
			HLA and Unacceptables Class II	DR
			HLA and Unacceptables Class II	DR
			HLA and Unacceptables Class II	DR51
			HLA and Unacceptables Class II	DR51
			HLA and Unacceptables Class II	DR52
			HLA and Unacceptables Class II	DR52
			HLA and Unacceptables Class II	DR53
			HLA and Unacceptables Class II	DR53
			HLA and Unacceptables Class II	DQB1
			HLA and Unacceptables Class II	DQB1
			HLA and Unacceptables Class II	DQA1
			HLA and Unacceptables Class II	DQA1
			HLA and Unacceptables Class II	DPB1
			HLA and Unacceptables Class II	DPB1
			HLA and Unacceptables Class II	DPA1
			HLA and Unacceptables Class II	DPA1
			HLA and Unacceptables Testing and Review of Unacceptables	Tested for anti HLA antibodies
			HLA and Unacceptables Testing and Review of Unacceptables	If yes, most recent antibody test date
			HLA and Unacceptables Testing and Review of Unacceptables	Prior to a candidate appearing on their first match run, all unacceptable antigens in KPD must be reviewed. Have all the candidate’s unacceptable antigens been reviewed?
			HLA and Unacceptables Unacceptable Antigens	CPRA value used for allocation per OPTN policy	This field cannot be updated on this screen
			HLA and Unacceptables Unacceptable Antigens	Detailed CPRA value	This field cannot be updated on this screen
			HLA and Unacceptables Unacceptable Antigens	Select all A unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all B unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select BW unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all C unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all DR unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all DR 51 unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all DR 52 unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all DR 53 unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all DQB1 unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all DQA1 unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all DPB1 unacceptable antigens
			HLA and Unacceptables Unacceptable Antigens	Select all DPB1 unacceptable epitopes
			HLA and Unacceptables Unacceptable Antigens	Select all DPA1 unacceptable antigens
			HLA and Unacceptables All Other Antibody Specificities	Select all A other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all B other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select BW other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all C other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all DR other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all DR 51 other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all DR 52 unacceptable antigens
			HLA and Unacceptables All Other Antibody Specificities	Select all DR 53 unacceptable antigens
			HLA and Unacceptables All Other Antibody Specificities	Select all DQB1 other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all DQA1 other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all DPB1 other antibody specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all DPB1 other epitope specificities
			HLA and Unacceptables All Other Antibody Specificities	Select all DPA1 other antibody specificities
			Titers Institution	Home transplant center
			Titers-Titer Information	If the candidate is B, is the candidate willing to accept an A2 or A2B donor?	This question only displays if the candidate has an ABO blood type of B
			Titers-Titer Information	If the candidate is willing to accept an A2 donor or A2B donor, enter IgG antibody titer
			Titers-Titer Information	Titer
			Titers-Titer Information	Date
			Titers-Titer Information	Candidate current eligibility status for A2 and A2B donor	This is a read-only field
			Titers-Titer Information	If the candidate is O, is the candidate willing to accept an A2 donor?	This question only displays if the candidate has an ABO blood type of O
			Titers-Titer Information	If the candidate is willing to accept an A2 donor, enter anti-A titer
			Titers-Titer Information	Titer
			Titers-Titer Information	Date
			Titers-Titer Information	Candidate current eligibility status for A2 donor	This is a read-only field
			Verify Candidate ABO Candidate Information	Last name	This field is read-only
			Verify Candidate ABO Candidate Information	First name	This field is read-only
			Verify Candidate ABO Candidate Information	Middle initial	This field is read-only
			Verify Candidate ABO Candidate Information	ABO
			Verify Candidate ABO Candidate Information	Age	This field is read-only
			Verify Candidate ABO Candidate Information	Gender	This field is read-only
			Verify Candidate ABO Candidate Information	First user ABO entry	This field is read-only
			Donor Pre-Screen Candidate Information	KPD Candidate ID	Unique numeric ID generated by system. This field is read-only
			Donor Pre-Screen Candidate Information	Candidate name	This field is read-only
			Donor Pre-Screen Candidate Information	Candidate HLA	This field is read-only
			Donor Pre-Screen Candidate Information	Candidate CPRA	This field is read-only
			Donor Pre-Screen Candidate Information	Candidate unacceptable antigens	This field is read-only
			Donor Pre-Screen Candidate Information	All other antibody specificities	This field is read-only
			Donor Pre-Screen Candidate Information	Candidate ABO	This field is read-only
			Potential donors available for pre-screening	KPD Donor ID	This field is read-only
			Potential donors available for pre-screening	Donor HLA	This field is read-only
			Potential donors available for pre-screening	BMI/Height/Weight	This field is read-only
			Potential donors available for pre-screening	Creatinine Clearance (ml/min)	This field is read-only
			Potential donors available for pre-screening	GFR (isotopic method) (ml/min/1.73 m2)	This field is read-only
			Potential donors available for pre-screening	Age	This field is read-only
			Potential donors available for pre-screening	M/F	This field is read-only
			Potential donors available for pre-screening	ABO	This field is read-only
			Potential donors available for pre-screening	Kidney choice	This field is read-only
			Potential donors available for pre-screening	Left kidney arteries	This field is read-only
			Potential donors available for pre-screening	Left kidney veins	This field is read-only
			Potential donors available for pre-screening	Left kidney ureter	This field is read-only
			Potential donors available for pre-screening	Right kidney arteries	This field is read-only
			Potential donors available for pre-screening	Right kidney veins	This field is read-only
			Potential donors available for pre-screening	Right kidney ureter	This field is read-only
			Potential donors available for pre-screening	Pre-accept/Pre-refuse
			Potential donors available for pre-screening	Pre-screen last updated
			Potential donors available for pre-screening	Donor last updated	This field is read-only
			Donor Pre-Screen Donors pre-refused	KPD Donor ID	This field is read-only
			Donor Pre-Screen Donors pre-refused	Donor HLA	This field is read-only
			Donor Pre-Screen Donors pre-refused	BMI/Height/Weight	This field is read-only
			Donor Pre-Screen Donors pre-refused	Creatinine clearance (ml/min)	This field is read-only
			Donor Pre-Screen Donors pre-refused	GFR (isotopic method) (ml/min/1.73 m2)	This field is read-only
			Donor Pre-Screen Donors pre-refused	Age	This field is read-only
			Donor Pre-Screen Donors pre-refused	M/F	This field is read-only
			Donor Pre-Screen Donors pre-refused	ABO	This field is read-only
			Donor Pre-Screen Donors pre-refused	Kidney choice	This field is read-only
			Donor Pre-Screen Donors pre-refused	Left kidney arteries	This field is read-only
			Donor Pre-Screen Donors pre-refused	Left kidney veins	This field is read-only
			Donor Pre-Screen Donors pre-refused	Left kidney ureter	This field is read-only
			Donor Pre-Screen Donors pre-refused	Right kidney arteries	This field is read-only
			Donor Pre-Screen Donors pre-refused	Right kidney veins	This field is read-only
			Donor Pre-Screen Donors pre-refused	Right kidney ureter	This field is read-only
			Donor Pre-Screen Donors pre-refused	Pre-accept/Pre-refuse
			Donor Pre-Screen Donors pre-refused	Pre-screen last updated	This field is read-only
			Donor Pre-Screen Donors pre-refused	Donor last updated	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	KPD Donor ID	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Donor HLA	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	BMI/Height/Weight	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Creatinine Clearance (ml/min)	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	GFR (isotopic method) (ml/min/1.73 m2)	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Age	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	M/F	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	ABO	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Kidney choice	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Left kidney arteries	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Left kidney veins	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Left kidney ureter	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Right kidney arteries	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Right kidney veins	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Right kidney ureter	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Pre-accept/Pre-refuse
			Donor Pre-Screen-Donors pre-accepted	Pre-screen last updated	This field is read-only
			Donor Pre-Screen-Donors pre-accepted	Donor last updated	This field is read-only
			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].