Donor ID: Donor ID displays. This field is read-only.
OPO: Select OPO from drop-down list. This is a required field.
Donor hospital: Select donor hospital from drop-down list. This is a required field.
Time zone: Select time zone of where the donor hospital is located from drop-down list. This is a required field.
Eastern
Central
Mountain
Pacific
Alaska
Hawaii
Atlantic
Is Daylight Savings Time observed?:
Yes
No
Last Name: Enter the donor’s last name. This field is required.
First Name: Enter the donor’s first name. This field is required.
Middle Initial: Enter the donor’s middle initial.
KDPI: (Kidney Donor Profile Index) This field is read-only.
ABO: Select donor’s ABO information. This is a required field.
A
A1
A1B
A2
A2B
B
AB
O
Date of birth: Enter the donor’s date of birth. A calendar link is available.
Format: MM/DD/YYYY
Age (Value): The donor’s age is populated automatically by the system based on the date of birth entered. This is a required field.
Range: 0–1188 (months)
Age (Unit):
Months
Years
Height: Enter the donor’s height in feet and inches or centimeters. This is a required field.
Feet range: 0–7
Inches range: 0–11
Centimeters range: 1–241.3
Weight: Enter the donor’s weight in pounds or kilograms. This is a required field.
Lbs range: 2–650
Kg range: 0.454–294.8
BMI: Body Mass Index – a measure that adjusts body weight for height. The BMI is calculated based on the ratio of the weight of the body in kilograms to the square of its height in meters. This field is populated automatically by the system when height and weigh are entered.
Cause of death: Select the cause of death. This is a required field.
Anoxia
Cerebrovascular/stroke
Head trauma
CNS tumor
Other, specify
If Other, specify: Enter the cause of death.
Admit date and time: Enter the admission date and time. A calendar link is available.
Format: MM/DD/YYYY and HH:MM
Note: Time should be in 24-hour format.
Mechanism of injury: Select the mechanism of injury.
Drowning
Seizure
Drug intoxication
Asphyxiation
Cardiovascular
Electrical
Gunshot wound
Stab
Blunt injury
SIDS
Intracranial hemorrhage/stroke
Death from natural causes
None of the above
Pronouncement of death date and time: Enter the death pronouncement date and time. A calendar link is available.
Format: MM/DD/YYYY and HH:MM
Note: Time should be in 24-hour format
Circumstance of death: Select the circumstances of death.
MVA
Suicide
Homicide
Child abuse
Accident
Non-MVA
Death from natural causes
None of the above
Cold ischemic time: Total cold ischemic time displays in HH:MM. After 72 hours, "Expired" displays instead of the clock.
OR Date (status): Select the status of OR date.
Not Set
Tentative
Scheduled
OR Date (date and time): Record the Operating Room (OR) date and time.
Note: Time should be entered in 24-hour format, and should be entered based on the Donor Hospital local time.
Recovery Facility: Indicate the Recovery Facility, by selecting Donor Hospital or Alternate Facility. If OR status is set to Tentative or Scheduled, you must indicate the Recovery Facility.
Recovery Facility (Alternate Facility Text): If alternate facility is selected, enter the name of the facility in the space provided.
Donor meets DCD criteria: Indicate if the donor meets the donation after Circulatory Death criteria. This is a required field.
Yes
No
Cardiac arrest / downtime?: Indicate if the donor experienced cardiac arrest.
Yes
No
Unknown
Duration: If the donor experienced cardiac arrest, enter the amount of downtime, in minutes, in the space provided.
CPR administered?: Indicate if CPR was administered.
Yes
No
Unknown
Duration: If CPR was administered, enter the amount of downtime, in minutes, in the space provided.
Ethnicity: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of ethnicity is aligned to this standard.
OMB defines ethnicity to be whether or not a person self-identifies as Hispanic or Latino. For this reason, ethnicity is broken out into two categories, (1) Hispanic or Latino or (2) Not Hispanic or Latino. Select one ethnicity category or select 'Ethnicity Not Reported' if a category was not self-identified by the person.
This field is required.
Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Not Hispanic or Latino
Ethnicity Not Reported – Select if person did not self-identify an ethnicity category.
Race: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of race is aligned to this standard. OMB defines race as a person’s self-identification with one or more social groups.
An individual can select one or more race categories (1) White, (2) Black or African American, (3) Asian, (4) American Indian or Alaska Native, (5) Native Hawaiian or Other Pacific Islander, or Race Not Reported.
This field is required.
Select one or more race sub-categories or origins. Select 'Other Origin' if origin is not listed. Select 'Origin Not Reported' if the origin was not self-identified by the person.
White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
European Descent
Arab or Middle Eastern
North African (non-Black)
Other Origin
Origin Not Reported
Black or African American – A person having origins in any of the Black racial groups of Africa.
African American
African (Continental)
West Indian
Haitian
Other Origin
Origin Not Reported
American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
American Indian
Eskimo
Aleutian
Alaska Indian
Other Origin
Origin Not Reported
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Asian Indian/Indian Sub-Continent
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Origin
Origin Not Reported
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Origin
Origin Not Reported
Race Not Reported – Select if person did not self-identify a race category or origin.
Donor Highlights: Enter any important comments concerning the donor. 5000 character limit.
Admission course comments: Enter any comments concerning admission course. 5000 character limit.
History of diabetes: Indicate if the donor has a documented history of diabetes mellitus prior to this hospitalization. A donor should not be considered as having a history of diabetes based on gestational diabetes only. This is a required field.
No
Yes, 0-5 years
Yes, 6-10 years
Yes, >10 years
Yes, duration unknown
Unknown
History of cancer: Indicate if the donor has a documented history of any type of cancer prior to this hospitalization.
No
Skin-squamous, basal cell
Skin, melanoma
CNS tumor-astrocytoma
CNS tumor-glioblastoma multiforme
CNS tumor-medulloblastoma
CNS tumor-neuroblastoma
CNS tumor-angioblastoma
CNS tumormeningioma
CNS tumor-other
Genitourinary-bladder
Genitourinary-uterine cervix
Genitourinary-uterine body endometrial
Genitourinary-uterine body choriocarcinoma
Genitourinary-vulva
Genitourinary-ovarian
Genitourinary-penis, testicular
Genitourinary-prostate
Genitourinary-kidney
Genitourinary-unknown
Gastrointestinal-esophageal
Gastrointestinal-stomach
Gastrointestinal-small intestine
Gastrointestinal-colo-rectal
Gastrointestinal-liver & biliary tract
Gastrointestinal-pancreas
Breast
Thyroid
Tongue/throat
Larynx
Lung (include bronchial)
Leukemia/lymphoma
Unknown
Other, Specify
Other, Specify: Enter the type of cancer in the space provided.
History of hypertension: Indicate if the donor has a documented history of hypertension prior to this hospitalization. This is a required field.
No
Yes, 0-5 years
Yes, 6-10 years
Yes, >10 years
Yes, duration unknown
Unknown
Compliant with treatment: Indicate if the donor was compliant with treatment. This field is required.
Yes
No
Unknown
History of coronary artery disease (CAD): Indicate if the donor had a history of coronary artery disease. This is field is required.
Yes
No
Unknown
Previous gastrointestinal disease: Indicate if the donor had a history of gastrointestinal disease. This is a required field.
Yes
No
Unknown
Chest trauma: Indicate if the donor had chest trauma.
Yes
No
Unknown
Cigarette use (>20 pack years) ever: If the donor has ever used cigarettes for more than 20 pack years, select Yes. If the donor has never used cigarettes or the usage is less than 20 pack years, select No. If cigarette usage is unknown, select Unknown. Vaping and e-cigarette usage is not collected in this field. This field is required.
Yes
No
Unknown
And continued in last six months: Indicate if the donor has continued smoking in the last six months.
Yes
No
Unknown
Heavy alcohol use (2+ drinks/day): Indicate if the donor has a history of having more than 2 alcoholic drinks per day. This field is required.
Yes
No
Unknown
I.V. drug usage: Indicate if the donor had a history of intravenous drug use. This field is required.
Yes
No
Unknown
According to the OPTN policy in effect on the date of referral, does the donor have risk factors for blood-borne disease transmission?: This field is read-only.
Sex (i.e., any method of sexual contact, including vaginal, anal, and oral) with a person known or suspected to have HIV, HBV, or HCV infection:
Yes
No
Man who has had sex with another man:
Yes
No
Sex in exchange for money or drugs:
Yes
No
Sex with a person who had sex in exchange for money or drugs:
Yes
No
Drug injection for nonmedical reasons:
Yes
No
Sex with a person who injected drugs for nonmedical reasons:
Yes
No
Incarceration (confinement in jail, prison, or juvenile correction facility) for ≥72 consecutive hours:
Yes
No
Child breastfed by a mother with HIV infection:
Yes
No
N/A
Child born to a mother with HIV, HBV, or HCV infection:
Yes
No
N/A
Unknown medical or social history:
Yes
No
History of myocardial infarction:
Yes
No
Unknown
Medical and social history comments: Enter any comments concerning medical and/or social history.
Donor Management Indicators – Range
Begin Date: Enter the starting date the vital signs were taken (MM/DD/YYYY). A calendar link is available.
Begin Time: Enter the starting time (HH:MM) the vital signs were taken.
Note: Time should be in 24-hour format.
End Date: Enter the ending date (MM/DD/YYYY) the vital signs were taken. A calendar link is available.
End Time: Enter the ending time (HH:MM) the vital signs were taken.
Note: Time should be in 24-hour format.
Average or Actual BP: Enter the systolic and diastolic blood pressure values for the average or actual blood pressure. This is a required field.
Range: 0–300 (systolic) and 0–200 (diastolic)
Heart Rate: Enter the heart rate in beats per minute. This is a required field.
Range: 1–225
High Blood Pressure: Enter the systolic and diastolic values for the highest blood pressure.
Range: 0–300 (systolic) and 0–200 (diastolic)
Duration at high: Enter the duration of the blood pressure at its highest in minutes.
Range: 1–2880
Low Blood Pressure: Enter the systolic and diastolic values for the lowest blood pressure.
Range: 0–300 (systolic) and 0–200 (diastolic)
Duration at Low: Enter the duration of the blood pressure at its lowest in minutes.
Range: 1–2880
Core Body Temp: Enter the range of core body temperature. Indicate if temperature is entered in Celsius or Fahrenheit.
Range: 26.7–110.1
Urine output (cc/hour): Enter the value in cc/hour. This is a required field.
Range: 0–5000
CVP (mm/Hg): Enter the central venous pressure in mm/Hg.
Range: 0–50
PA Pressure Systolic: Enter the systolic pulmonary artery (pa) pressure value in mm/Hg.
Range: 0–300
PA Pressure Diastolic: Enter the diastolic pulmonary artery (pa) pressure value in mm/Hg.
Range: 0–200
PCWP: Enter the pulmonary capillary wedge pressure value in mm/Hg.
Range: 0–50
PAMP: Enter the pulmonary artery mean pressure value in mm/Hg.
Range: 0–50
Cardiac Output / Cardiac Input: Enter the Cardiac Output in L/min and Cardiac Input in L/min/sq.m. The user may also select to only enter a single value (the first part of the range) or both values in a range.
Cardiac Output Range: 0.2–15
Cardiac Input Range: 0–50
Donor Management Indicators – Hourly
Begin Date: Enter the starting date the vital signs were taken (MM/DD/YYYY). A calendar link is available.
Begin Time: Enter the starting time (HH:MM) the vital signs were taken.
Note: Time should be in 24-hour format.
Average or Actual BP: Enter the systolic and diastolic blood pressure values for the average or actual blood pressure. This is a required field.
Range: 0–300 (systolic) and 0–200 (diastolic)
Heart Rate: Enter the heart rate in beats per minute. This is a required field.
Range: 1–225
Core Body Temp: Enter the range of core body temperature. Indicate if temperature is entered in Celsius or Fahrenheit.
Range: 26.7–110.1
CVP (mm/Hg): Enter the central venous pressure in mm/Hg.
Range: 0–50
PA Pressure Systolic: Enter the systolic pulmonary artery (pa) pressure value in mm/Hg.
Range: 0–300
PA Pressure Diastolic: Enter the diastolic pulmonary artery (pa) pressure value in mm/Hg.
Range: 0–200
PCWP: Enter the pulmonary capillary wedge pressure value in mm/Hg.
Range: 0–50
PAMP: Enter the pulmonary artery mean pressure value in mm/Hg.
Range: 0–50
Cardiac Output / Cardiac Input: Enter the Cardiac Output in L/min and Cardiac Input in L/min/sq.m. The user may also select to only enter a single value (the first part of the range) or both values in a range.
Cardiac Output Range: 0.2–15
Cardiac Input Range: 0–50
Vital Signs Comments: Enter any comments concerning the vital signs.
Complete Blood Count (CBC)
Date: Enter the date (MM/DD/YYYY) the blood count was obtained. A calendar link is available.
Time: Enter the time (HH:MM) the blood count was obtained.
Note: Time should be in 24-hour format.
WBC (thous/mcL): (White Blood Cells) Enter the value in thous/mcL.
Range: 1–25
RBC (thous/mcL): (Red Blood Cells) Enter the value in thous/mcL.
Range: 1–25
HgB (g/dL): (Hemoglobin) Enter the value in g/dL.
Range: 1–30
Hct (%): (Hematocrit) Enter the value in %.
Range: 0–75
Plt (thous/mcL): (Platelets) Enter the value in thous/mcL.
Range: 50–500
Bands (%): Enter the value in %.
Range: 0–25
Lab Panel
Date: Enter the date (MM/DD/YYYY) the lab panel was obtained. A calendar link is available.
Time: Enter the time (HH:MM) the lab panel was obtained.
Note: Time should be in 24-hour format.
Serum Sodium (mEq/L): (Sodium) Enter the lab value in mEq/L. This is a required field.
Range: 0–99,999
K+ (mmol/L): (Potassium) Enter the lab value in mmol/L.
Range: 0–999.9
Cl (mmol/L): (Chloride) Enter the lab value in mmol/L.
Range: 0–9999
CO2 (mmol/L): Enter the lab value in mmol/L.
Range: 0–999.9BUN (mg/dL)
BUN (mg/dL): Enter the lab value in mg/dL. This is a required field.
Range: 0–9999
Creatinine (mg/dL): Enter the lab value in mg/dL. This is a required field.
Range: 0.01–40
Glucose (mg/dL): Enter the lab value in mg/dL. This is a required field.
Range: 0–9999
Total Bilirubin (mg/dL): Enter the lab value in mg/dl. This is a required field.
Range: 0–9999.9
Direct Bilirubin (mg/dL): Enter the lab value mg/dL.
Range: 0–9999.9
Indirect Bilirubin (mg/dL): Enter the lab value in mg/dL.
Range: 0–9999.9
SGOT (AST) (u/L): (Serum Glutamic Oxaloacetic Transaminase/Aspartate Transaminase) Enter the lab value in U/L. This is a required field.
Range: 1–36,000
SGPT (ALT) (u/L): (Serum Glutamic Pyruvic Transaminase/Alanine Aminotransferase) Enter the lab value in U/L. This is a required field.
Range: 1–50000
Alkaline phosphatase (u/L): Enter the lab value in units/L.
Range: 0–9999
GGT (u/L): Enter the lab value in u/L.
Range: 0–9999
LDH (u/L): Enter the lab value in u/L.
Range: 0–99,999
Albumin (g/dL): Enter the lab value in g/dL.
Range: 0–999.99
Total protein (g/dL): Enter the value in g/dL.
Range: 0–999.9
Prothrombin (PT) (seconds): Enter the lab value in seconds. This is a required field.
Range: 0–9999.9
INR: (International Normalized Ratio) Enter the lab value.
Range: 0–999.99
PTT (seconds): Enter the lab value in seconds.
Range: 0–9999.9
Serum Amylase (u/L): Enter the lab value in u/L. This is a required field.
Range: 0–9999.99
Serum Lipase (u/L): Enter the lab value in u/L. This field is required for pancreas, kidney-pancreas and pancreas islet electronic organ offers.
Range: 0–9999.99
Serum Lipase Upper Normal Limit (u/L): Enter the lab value (i.e., maximum normal value or highest reference value) in u/L. This field is required for pancreas, kidney-pancreas and pancreas islet electronic organ offers.
Range: 0–9999.99
Urinalysis
Date: Enter the date (MM/DD/YYYY) the urinalysis was obtained. A calendar link is available.
Time: Enter the time (HH:MM) the urinalysis was obtained.
Note: Time should be in 24-hour format.
Color: Enter the value.
Appearance: Enter the value.
pH: Enter the value.
Range: 5–10
Specific gravity: Enter the value.
Range: 1–1.5
Protein: Select the result of the test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
Glucose: Select the result of the test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
Blood: Select the result of the test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
RBC: (Red Blood Cells) Select the result of the test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
WBC: (White Blood Cells) Select the result of the test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
Epith (%): Select the result of the epithelial cells test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
Casts: Select the result of the test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
Bacteria: Select the result of the test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
Leukocyte esterase: Select the result of the test from the drop-down list.
Positive
Negative
If positive, enter any results and/or comments concerning the test in the space provided.
ABGS/Ventilator Settings
Date: Enter the date (MM/DD/YYYY) the ABGs were obtained. A calendar link is available. This is a required field.
Time: Enter the time (HH:MM) the ABGs were obtained. This is a required field.
Note: Time should be in 24-hour format.
pH: Enter the value. This is a required field.
Range: 5–8
PaCO2 (mmHg): Enter the value in mmHg. This is a required field.
Range: 0–999.9
PaO2 (mmHg): (Partial Pressure of Arterial Oxygen) Enter the value in mmHg. This is a required field.
Range: 0–999.9
HCO3 (mEq/L): Enter the value in mEq/L. This is a required field.
Range: 0–99.9
SaO2 (%): Enter the value in %. This is a required field.
Range: 50–100
Mode: Select the mode from the drop-down list. This is a required field.
NC
CPAP
BiPAP
SIMV
A/C
CMV
Other
If Other, enter the mode.
FiO2 (%): Enter the value in %. This is a required field.
Range: 20–100
RR: Enter the rate. This is a required field.
Range: 1–250
VT (cc): (Tidal Volume) Enter the value. This is a required field.
Definition: The volume of each breath delivered by a ventilator.
Range: 10–2000
PEEP (cmH2O): (Positive End-Expiratory Pressure) Enter the value. This is a required field.
Range: 0–25
Lab Values
Date: Enter the date (MM/DD/YYYY) the ABGs were obtained. A calendar link is available.
Time: Enter the time (HH:MM) the ABGs were obtained.
Note: Time should be in 24-hour format.
CPK(u/L): Enter the value in u/L.
Range: 0–99999
CK-MB(ng/mL): Enter the value in ng/mL.
Range: 0–9999.9
Troponin I (ng/mL): Enter the value in ng/mL.
Range: 0–9999.99
Troponin T (ng/mL): Enter the value in ng/mL.
Range: 0–9999.99
Toxicology Screen: Indicate if a toxicology screen was completed.
Yes
No
Results: If yes, enter results and/or comments concerning the toxicology screen.
HbA1C (%): Enter the HbA1C.
Range: 2–15%
HbA1C (%) Date: Enter the date (MM/DD/YYY) the HbA1C was obtained. A calendar link is available.
HbA1C (%) Time: Enter the time (HH:MM) the HbA1C was obtained.
Note: Time should be in 24-hour format.
Other labs, specify: Enter any information concerning additional labs.
Cultures/Microbiology
Date: Enter the collection date (MM/DD/YYYY). A calendar link is available.
Time: Enter the collection time (HH:MM).
Note: Time should be in 24-hour format.
Type: Select the type from the drop-down list. If Other is selected, enter the type in the space provided.
Blood
Urine
Sputum gram stain
Dputum culture
CSF
Other
Result: Indicate the result.
Positive
Negative
Pending
Comments: Enter any comments concerning cultures/microbiology.
Note: Adding new lab data and editing existing lab data, will be allowed for a period of 180 days after the Donor Add date.
Inotropic Medication: Select the medication from the drop-down list. If Other, specify is selected, enter the medication in the space provided.
Dopamine
Dobutamine
Epinephrine
Levophed
Neosynephrine
Isoproterenol (Isuprel)
Other, specify
Begin Date: Enter the date the administration of inotropic medication began. A calendar link is available.
Format: MM/DD/YYYY
Begin Time: Enter the time the administration of inotropic medication began.
Format: HH:MM
Note: Time should be in 24-hour format.
End Date: Enter the date the administration of inotropic medication ended. A calendar link is available.
Format: MM/DD/YYYY
End Time: Enter the time the administration of inotropic medication ended.
Format: HH:MM
Note: Time should be in 24-hour format
Value: Enter the inotropic medication value.
Range: 0.001–500
Units: Select the unit type from the drop-down list.
mcg/kg/min
mcg/min
mg/min
units/hr
mcg/hr
I.V. fluids: (Intravenous) Enter the value in cc/hour.
Range: 1–9999
Steroids: Indicate if steroids were administered within 24 hours prior to cross-clamp.
Yes
No
If Yes, specify: Enter the name of the steroid in the space provided.
Diuretics: Indicate if diuretics were administered within 24 hours prior to cross-clamp.
Yes
No
If Yes, specify: Enter the name of the diuretic in the space provided.
T3: Indicate if T3 was administered within 24 hours prior to cross-clamp.
Yes
No
T4: Indicate if T4 was administered within 24 hours prior to cross-clamp.
Yes
No
Insulin: Indicate if insulin was administered within 24 hours prior to cross-clamp.
Yes
No
Begin Date: Enter the begin date (MM/DD/YYYY). A calendar link is available.
Begin Time: Enter the begin time (HH:MM).
Note: Time should be in 24-hour format.
End Date: Enter the end date (MM/DD/YYYY). A calendar link is available.
End Time: Enter the end time (HH:MM).
Note: Time should be in 24-hour format.
Antihypertensives: Indicate if antihypertensives were administered within 24 hours prior to cross-clamp.
Yes
No
Vasodilators: Indicate if vasodilators were administered within 24 hours prior to cross-clamp.
Yes
No
Begin Date: Enter the begin date (MM/DD/YYYY). A calendar link is available.
Begin Time: Enter the begin time (HH:MM).
Note: Time should be in 24-hour format.
End Date: Enter the end date (MM/DD/YYYY). A calendar link is available.
End Time: Enter the end time (HH:MM).
Note: Time should be in 24-hour format.
DDAVP: Indicate if DDAVP (synthetically derived vasopressor) was administered within 24 hours prior to cross-clamp.
Yes
No
Arginine vasopressin: Indicate if arginine vasopressin (human- or animal-derived vasopressor) was administered within 24 hours prior to cross-clamp.
Yes
No
Begin Date: Enter the begin date (MM/DD/YYYY). A calendar link is available.
Begin Time: Enter the begin time (HH:MM).
Note: Time should be in 24-hour format.
End Date: Enter the end date (MM/DD/YYYY). A calendar link is available.
End Time: Enter the end time (HH:MM).
Note: Time should be in 24-hour format.
Total Parenteral Nutrition: Indicate if Total Parenteral Nutrition was administered.
Yes
No
Heparin: Indicate if Heparin was administered.
Yes
No
Begin Date: Enter the begin date (MM/DD/YYYY). A calendar link is available.
Begin Time: Enter the begin time (HH:MM).
Note: Time should be in 24-hour format.
End Date: Enter the end date (MM/DD/YYYY). A calendar link is available.
End Time: Enter the end time (HH:MM).
Note: Time should be in 24-hour format.
Units: Enter the number of units administered.
Values: 100 to 900 in increments of 100 then 1,000 to 50,000 in increments of 1,000.
Other/specify 1: Enter the name of any other medications administered.
Other/specify 2: Enter the name of any other medications administered.
Other/specify 3: Enter the name of any other medications administered.
Transfusions/Blood Products
Transfusions prior to ABO determination:
Yes
No
Total number: Enter the total number of transfusions.
Total volume: Enter the total volume.
Transfusions following ABO determination:
Yes
No
Total number: Enter the total number of transfusions.
Total volume: Enter the total volume.
Other blood products: Indicate if any other blood products were received by the donor.
Yes
No
If Yes, specify: Enter the type of blood product in the space provided
Anti-HBc: (Hepatitis B Virus) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. This is a required field.
Anti-HBc – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Values: Positive; Negative; Not Done; Indeterminate, Pending
HBV NAT: Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. This is a required field.
HBV NAT – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Values: Positive; Negative; Not Done; Indeterminate, Pending
HBsAg: (Hepatitis B Surface Antigen) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No or Unknown from the drop-down list of options.
HBsAg – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
HBsAb: (Hepatitis B Surface Antibody) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No or Unknown from the drop-down list of options.
HBsAb – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Anti-HCV: (Hepatitis C Virus) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. This is a required field.
Anti-HCV – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
HCV NAT: (Hepatitis C Nucleic Acid Amplification Testing) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. This is a required field.
HCV NAT – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Anti-HIV I/II: (Human Immunodeficiency Virus) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. This is a required field.
Anti-HIV I/II – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
HIV Ag/Ab Combo: Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. This is a required field.
HIV Ag/Ab Combo – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
HIV NAT: (Human Immunodeficiency Virus Nucleic Acid Testing) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. This is a required field.
HIV NAT – Hemodiluation: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Anti-HTLV I/II: (Human T-cell Lymphotrophic (or Leukemia) Virus) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
Anti-HTLV I/II – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
HTLV NAT: (Human T-cell Lymphotrophic (or Leukemia) Virus Nucleic Acid Testing) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
HTLV NAT – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Anti-CMV: (Cytomegalovirus) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. This is a required field.
Anti-CMV – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Syphilis: Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
Syphilis – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
EBV (VCA) (IgG): (Epstein-Barr Virus/Viral Capsid Antigen) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
EBV (VCA) (IgG) – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Note: A titer level of <1:10 is considered Negative.
EBV (VCA) (IgM): (Epstein-Barr Virus/Viral Capsid Antigen) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
EBV (VCA) (IgM) – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Note: A titer level of <1:10 is considered Negative.
EBNA: (Epstein-Barr Virus) Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
EBNA – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Note: A titer level of <1:10 is considered Negative.
Toxoplasma (IgG): Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
Toxoplasma (IgG) – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Screening for toxoplasma is a way to increase transplant recipient safety by potentially decreasing the number of unexpected transmissions of toxoplasma gondii.
Positive
Negative
Not Done
Indeterminate
Pending
Chagas: Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
Chagas – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Chagas NAT: Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No or Unknown from the drop-down list of options.
Chagas NAT – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
West Nile: Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
West Nile – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
West Nile NAT: Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
West Nile NAT – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Strongyloides: Indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options.
Strongyloides – Hemodilution: Select the result of the test. If a test has been run but results have not been received, select Pending. If it is not known if a test has been run, select Not Done. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate. Only Positive and Negative values cascade to the TIEDI DDR record. This field is used for screening.
Positive
Negative
Not Done
Indeterminate
Pending
Other Infectious Diseases
OPOs can record whether testing was performed on the donor and have the ability to report more than one test result. Entering this information is not mandatory.
Was COVID-19 (SARS-CoV-2) testing performed on the donor?: Indicate whether COVID-19 testing was performed on the donor. Select Yes, No, or Unknown from the choices. If “Yes” is chosen, additional data collection fields display. This is a required field.
Specimen Date: Enter the date (MM/DD/YYYY) the test was performed. A calendar link is available.
Specimen Time: Enter the time (HH:MM) the test was performed.
Specimen Type: Select the type of the type of specimen from the drop-down list of options. Note: For specimens only, an indication of whether the specimen was hemodiluted.
Upper Respiratory (e.g. (NP) nasopharyngeal swab)
Examples include: Nasopharyngeal (NP) swab, nasopharyngeal wash/aspirate, nasal wash/aspirate, oropharyngeal (OP) swab.
Lower Respiratory (e.g. tracheal aspirate, (BAL) bronchoalveolar lavage)
Examples include: Bronchoalveolar lavage (BAL), lower respiratory tract aspirate/wash, sputum, tracheal aspirate.
Blood
Examples include: Plasma, serum, whole blood.
Other, specify
Hemodiluted Specimen: If the specimen type is “blood”, then indicate whether the specimen that was used for the test was hemodiluted. Select Yes, No, or Unknown from the drop-down list of options. If the specimen type is not blood, then leave blank.
Test Method: Select the test method from the drop-down list of options.
Nucleic acid detection (e.g. real time RT-PCR)
Antibody (e.g. IgG/IgM/IgA)
Antigen
Other, specify
Result: Select the result of the test from the drop-down list of options. If a test has been run but results have not been received, select Pending. If the results from an infectious disease test were inconclusive or equivocal, select Indeterminate.
Note: OPO users: Please be sure to include in your process steps to update with the final result. The result must be updated in DonorNet because the COVID-19 test data collection is not available on the TIEDI® DDR. Similar to culture reporting, the new COVID-19 test section will remain editable after Donor Organ Disposition (feedback) is complete.
Positive
Negative
Indeterminate
Pending
Comments: Enter documentation of other pertinent information regarding the test, such as when pending results are expected back. This field is optional.
Add New Tests
Test Type: Select the test type from the drop-down list.
Angiography
Bronchoscopy
Cardiac catheterization
Chest x-ray
CT/MRI
Echocardiograms
EKGs
Ultrasounds
Other, specify
If Other, specify: Enter the type of test.
Test Date: Enter the date the test (MM/DD/YYYY) was administered. A calendar link is available.
Test Time: Enter the time (HH:MM) the test was administered.
Diagnostic evaluation/comments: Enter any comments concerning the diagnostic evaluation.
Attach medical image: Indicate if a medical image is to be attached.
Yes
No
Attachment Description: Enter a brief description of the medical image.
Attachment File: Enter the file name of the image. You may also use the Browse feature.
Study Date: The date and time of the study displays. Studies may be referred to as any of the following:
DICOM Image
Imaging Study
Echo, CT Scan, X-Ray, Ultra-Sound, etc.
Attachment Description: Enter a description of the attached file.
Attachment File: File name.
Attachment Category: Select attachment category.
Class I: These are required fields.
A: Select an A Locus code from the drop-down list. This data copies over to the TIEDI DHS record.
Values: 1, 01:01, 01:02, 2, 02:01, 02:02, 02:03, 02:05, 02:06, 02:07, 02:10, 02:18, 3, 03:01, 03:02, 9, 10, 11, 11:01, 11:02, 19, 23, 24, 24:02, 24:03, 25, 26, 26:01, 26:02, 26:03, 28, 29, 29:01, 29:02, 30, 30:01, 30:02, 31, 32, 32:04, 33, 33:01, 33:03, 34, 34:01, 34:02, 36, 43, 66, 66:01, 66:02, 68, 68:01, 68:02, 69, 74, 80
B: Select a B Locus code from the drop-down list. This data copies over to the TIEDI DHS record.
Values: 5, 7, 07:02, 07:03, 07:14, 8, 08:01, 08:02, 08:03, 08:04, 12, 13, 13:01, 13:02, 14, 14:01, 14:02, 15, 15:01, 15:02, 15:03, 15:04, 15:06, 15:07, 15:10, 15:11, 15:12, 15:13, 15:16, 15:17, 15:18, 15:20, 15:21, 15:24, 15:27, 16, 17, 18, 21, 22, 27, 27:03, 27:04, 27:05, 27:06, 27:08, 35, 35:01, 35:02, 35:03, 35:08, 35:12, 37, 38, 38:01, 38:02, 39, 39:01, 39:02, 39:04, 39:05, 39:06, 39:13, 40, 40:01, 40:02, 40:03, 40:04, 40:05, 40:06, 41, 41:01, 41:02, 42, 42:01, 42:02, 44, 44:02, 44:03, 45, 46, 47, 48, 48:01, 48:02, 49, 50, 50:01, 50:02, 51, 51:01, 51:02, 52, 53, 54, 55, 55:01, 55:02, 55:04, 56, 56:01, 56:03, 57, 57:01, 57:03, 58, 59, 60, 61, 62, 63, 64, 65, 67, 70, 71, 72, 73, 75, 76, 77, 78, 81, 82, 83:01
BW4: Select the result for the BW4 antigen from the drop-down list. This data copies over to the TIEDI DHS record.
Values: Positive; Negative
BW6: Select the result for the BW6 antigen from the drop-down list. This data copies over to the TIEDI DHS record.
Values: Positive; Negative
C: Select a C HLA code from the drop-down list. This data copies over to the TIEDI DHS record.
Values: 01, 01:02, 01:03, 02, 02:02, 02:10, 03, 03:02, 03:03, 03:04, 03:05, 03:06, 04, 04:01, 04:03, 04:04, 04:07, 05, 05:01, 06, 06:02, 07, 07:01, 07:02, 07:04, 07:06, 07:18, 08, 08:01, 08:02, 08:03, 08:04, 09, 10, 12, 12:02, 12:03, 12:04, 14, 14:02, 14:03, 15, 15:02, 15:04, 15:05, 15:06, 15:09, 16, 16:01, 16:02, 16:04, 17, 17:01, 17:03, 18, 18:01, 18:02
Class II: These are required fields.
DR: Select a DR Locus Code from the drop-down list. This data copies over to the TIEDI DHS record.
Values: 1, 01:01, 01:02, 01:03, 2, 3, 03:01, 03:02, 03:03, 4, 04:01, 04:02, 04:03, 04:04, 04:05, 04:06, 04:07, 04:10, 04:11, 5, 6, 7, 8, 08:01, 08:02, 08:03, 08:07, 9, 09:01, 09:02, 10, 11, 11:01, 11:03, 11:04, 12, 12:01, 12:02, 13, 13:01, 13:02, 13:03, 13:05, 14, 14:01, 14:02, 14:03, 14:04, 14:05, 14:06, 14:54, 15, 15:01, 15:02, 15:03, 16, 16:01, 16:02, 17, 18, 103
DR51: Select the result for the DR51 Locus from the drop-down list. This data copies over to the TIEDI DHS record.
Values: 51, 5*01, 5*01:01, 5*01:02, 5*02, 5*02:02, N-Negative
DR52: Select the result for the DR52 Locus from the drop-down list. This data copies over to the TIEDI DHS record.
Values: 52, 3*01, 3*01:01, 3*02, 3*02:01, 3*02:02, 3*03, 3*03:01, N-Negative
DR53: Select the result for the DR53 Locus from the drop-down list. This data copies over to the TIEDI DHS record.
Values: 53, 4*01, 4*01:01, 4*01:03, N-Negative
DQB1: Select a DQB1 HLA code from the drop-down list. This data copies over to the TIEDI DHR record.
Values: 2, 02:01, 02:02, 3, 03:01, 03:02, 03:03, 03:19, 4, 04:01, 04:02, 5, 05:01, 05:02, 05:03, 6, 06:01, 06:02, 06:03, 06:04, 06:09, 7, 8, 9
DQA1: Select a DQA1 HLA code from the drop-down list. This data copies over to the TIEDI DHR record.
Values: 01, 01:01, 01:02, 01:03, 01:04, 01:05, 01:06, 01:07, 01:08, 01:09, 01:10, 01:11, 01:12, 02, 02:01, 03, 03:01, 03:02, 03:03, 04, 04:01, 04:02, 04:03N, 04:04, 05, 05:01, 05:02, 05:03, 05:04, 05:05, 05:06, 05:07, 05:08, 05:09, 05:10, 05:11, 06, 06:01, 06:02
DPB1: Select a DPB1 HLA code from the drop-down list. This data copies over to the TIEDI DHR record.
Note:
For ambiguities involving “G”
alleles, you should report the lowest member of the “G”
allele string. For example, if your lab receives an 04:02/105:01
typing result, you should report 04:02.
Values: 01:01, 02:01, 02:02, 03:01, 04:01, 04:02, 05:01, 06:01, 08:01, 09:01, 10:01, 11:01, 13:01, 14:01, 15:01, 16:01, 17:01, 18:01, 19:01, 20:01, 21:01, 22:01, 23:01, 24:01, 25:01, 26:01, 27:01, 28:01, 29:01, 30:01, 31:01, 32:01, 33:01, 34:01, 35:01, 36:01, 37:01, 38:01, 39:01, 40:01, 41:01, 44:01, 45:01, 46:01, 47:01, 48:01, 49:01, 50:01, 51:01, 52:01, 53:01, 54:01, 55:01, 56:01, 57:01, 58:01, 59:01, 60:01, 62:01, 63:01, 65:01, 66:01, 67:01, 68:01, 69:01, 70:01, 71:01, 72:01, 73:01, 74:01, 75:01, 76:01, 77:01, 78:01, 79:01, 80:01, 81:01, 82:01, 83:01, 84:01, 85:01, 86:01, 87:01, 88:01, 89:01, 90:01, 91:01, 92:01, 93:01, 94:01, 95:01, 96:01, 97:01, 98:01, 99:01, 100:01, 101:01, 102:01, 103:01, 104:01, 105:01, 106:01, 107:01, 108:01, 109:01, 110:01, 111:01, 112:01, 113:01, 114:01, 115:01, 116:01, 117:01, 118:01, 119:01, 121:01, 122:01, 123:01, 124:01, 125:01, 126:01, 127:01, 128:01, 129:01, 130:01, 131:01, 132:01, 133:01, 134:01, 135:01, 136:01, 137:01, 138:01, 139:01, 140:01, 141:01, 142:01, 143:01, 144:01, 145:01, 146:01, 147:01, 148:01, 149:01, 150:01, 151:01, 152:01, 153:01, 155:01, 156:01, 157:01, 158:01, 160:01, 162:01, 163:01, 164:01, 165:01, 166:01, 167:01, 168:01, 169:01, 170:01, 171:01, 172:01, 173:01, 174:01, 175:01, 176:01, 177:01, 178:01, 179:01, 180:01, 181:01, 182:01, 183:01, 184:01, 185:01, 186:01, 187:01, 188:01, 189:01, 190:01, 191:01, 192:01, 193:01, 194:01, 195:01, 196:01, 197:01, 198:01, 199:01, 200:01, 201:01, 202:01, 203:01, 204:01, 205:01, 206:01, 207:01, 208:01, 209:01, 210:01, 211:01, 212:01, 213:01, 214:01, 215:01, 217:01, 219:01, 220:01, 221:01, 222:01, 223:01, 224:01, 225:01, 226:01, 227:01, 228:01, 229:01, 230:01, 231:01, 232:01, 233:01, 234:01, 235:01, 236:01, 237:01, 238:01, 239:01, 240:01, 241:01, 242:01, 243:01, 244:01, 245:01, 246:01, 247:01, 248:01, 249:01, 250:01, 251:01, 252:01, 253:01, 254:01, 255:01, 256:01, 257:01, 258:01, 259:01, 260:01, 261:01, 262:01, 263:01, 264:01, 265:01, 266:01, 267:01, 268:01, 269:01, 270:01, 271:01, 272:01, 273:01, 274:01, 275:01, 276:01, 277:01, 278:01, 279:01, 280:01, 281:01, 282:01, 283:01, 284:01, 285:01, 286:01, 287:01, 288:01, 289:01, 290:01, 291:01, 292:01, 293:01, 294:01, 295:01, 296:01, 297:01, 298:01, 299:01, 300:01, 301:01, 302:01, 303:01, 304:01, 305:01, 306:01, 307:01, 308:01, 309:01, 310:01, 311:01, 312:01, 313:01, 314:01, 315:01, 316:01, 317:01, 318:01, 319:01, 320:01, 321:01, 322:01, 323:01, 324:01, 325:01, 326:01, 327:01, 329:01, 330:01, 331:01, 332:01, 333:01, 334:01, 335:01, 336:01, 337:01, 338:01, 339:01, 340:01, 341:01, 342:01, 343:01, 344:01, 345:01, 346:01, 347:01, 348:01, 349:01, 350:01, 351:01, 352:01, 353:01, 354:01, 355:01, 356:01, 358:01, 359:01, 360:01, 361:01, 362:01, 363:01, 364:01, 365:01, 366:01, 367:01, 368:01, 369:01, 370:01, 371:01, 372:01, 373:01, 374:01, 375:01, 376:01, 377:01, 378:01, 379:01, 380:01, 381:01, 383:01, 384:01, 385:01, 386:01, 387:01, 388:01, 389:01, 390:01, 391:01, 392:01, 393:01, 394:01, 395:01, 396:01, 397:01, 398:01, 399:01, 400:01, 402:01, 404:01, 405:01, 406:01, 407:01, 408:01, 409:01, 410:01, 411:01, 412:01, 413:01, 414:01, 415:01, 416:01, 417:01, 418:01, 419:01, 420:01, 421:01, 422:01, 423:01, 424:01, 425:01, 426:01, 427:01, 428:01, 429:01, 430:01, 431:01, 432:01, 433:01, 434:01, 435:01, 436:01, 437:01, 438:01, 439:01, 440:01, 441:01, 442:01, 443:01, 444:01, 445:01, 446:01, 447:01, 448:01, 449:01, 451:01, 452:01, 453:01, 454:01, 456:01, 457:01, 458:01, 459:01, 460:01, 461:01, 462:01, 463:01, 464:01, 465:01, 466:01, 467:01, 468:01, 469:01, 470:01, 471:01, 472:01, 473:01, 474:01, 475:01, 476:01, 477:01, 478:01, 479:01, 480:01, 481:01, 482:01, 483:01, 484:01, 485:01, 486:01, 487:01, 488:01, 489:01, 490:01, 491:01, 492:01, 493:01, 494:01, 495:01, 496:01, 497:01, 498:01, 499:01, 500:01, 501:01, 502:01, 503:01, 504:01, 505:01, 506:01, 508:01, 509:01, 510:01, 511:01, 512:01, 513:01, 514:01, 515:01, 516:01, 517:01, 518:01, 519:01, 520:01, 521:01, 522:01, 523:01, 524:01, 525:01, 526:01, 527:01, 528:01, 529:01, 530:01, 531:01, 532:01, 533:01, 534:01, 535:01, 536:01, 537:01, 538:01, 539:01, 540:01, 541:01, 542:01, 543:01, 544:01, 545:01, 546:01, 547:01, 548:01, 549:01, 550:01, 552:01, 553:01, 554:01, 555:01, 556:01, 557:01, 558:01, 559:01, 560:01, 561:01, 562:01, 563:01, 564:01, 565:01, 566:01, 567:01, 568:01, 569:01, 571:01, 572:01, 573:01, 574:01, 575:01, 576:01, 577:01, 578:01, 579:01, 580:01, 581:01, 582:01, 583:01, 584:01, 585:01, 586:01, 587:01, 588:01, 589:01, 590:01, 591:01, 592:01, 593:01, 594:01, 595:01, 596:01, 597:01, 599:01, 600:01, 601:01, 602:01, 603:01, 604:01, 605:01, 606:01, 607:01, 608:01, 609:01, 610:01, 611:01, 612:01, 613:01, 614:01, 615:01, 616:01, 617:01, 618:01, 619:01, 620:01, 621:01, 622:01, 623:01, 624:01, 625:01, 626:01, 627:01, 628:01, 629:01, 630:01, 631:01, 632:01, 633:01, 634:01, 635:01, 636:01, 637:01, 638:01, 639:01, 640:01, 641:01, 642:01, 643:01, 644:01, 645:01, 646:01, 647:01, 648:01, 649:01, 650:01, 651:01, 652:01, 653:01, 654:01, 655:01, 656:01, 658:01, 659:01, 660:01, 662:01, 663:01, 664:01, Other allele
DPA1: Select a DPA1 HLA code from the drop-down list. This data copies over to the TIEDI DHR record.
Values: 01, 01:03, 01:04, 01:05, 01:06, 01:07, 01:08, 01:09, 01:10, 01:11, 01:12, 02, 02:01, 02:02, 02:03, 02:04, 02:07, 03, 03:01, 03:02, 03:03, 04, 04:01, Not tested
Crossmatch
Is there time for a preliminary crossmatch?: Indicate if there is time for a preliminary cross-match. This field defaults to yes. This is a required field.
Yes
No
Donor Information
Warm ischemic time (minutes): Enter the warm ischemic time in minutes. Warm ischemic time must be between 0 and 180 minutes.
Left Kidney
Left kidney biopsy: Indicate if a biopsy was performed on the left kidney. Only a Yes value copies over to the TIEDI DDR record.
Yes
No
% Glomerulosclerosis: Enter the value for the left kidney. This data copies over to the TIEDI DDR record.
Range: 0–99
Biopsy type: Select the biopsy type for the left kidney from the drop-down list.
Needle
Wedge
Number of Glomeruli: Enter the count.
Range: 0–300
Left Kidney Pump Values:
Pump Date: Enter the date (MM/DD/YYYY) the left kidney pump values were obtained. A calendar link is available.
Pump Time: Enter the time (HH:MM) the left kidney pump values were obtained.
Note: Time should be in 24-hour format.
Flow (cc/min): Enter the flow value for the left kidney pump in cc/min.
Pressure (mmHg) – Systolic: Enter the systolic pressure value for the left kidney pump in mmHg.
Range: 0–300
Pressure (mmHg) – Diastolic: Enter the diastolic pressure value for the left kidney pump in mmHg.
Range: 0–200
Resistance: Enter the resistance value for the left kidney pump.
Left kidney pump device: Select the left kidney pump device. If Other, specify is selected, enter the device type in the space provided.
ORS: LifePort
Waters: RM3
Waters: Waves
Other specify
Left kidney pump solution: Select the left kidney pump solution. If Other, specify is selected, enter the solution in the space provided.
Belzer
Silica gel
Other specify
Tissue preparation technique: This field is required.
Frozen section
FPPE section
Unknown
Number of globally sclerotic glomeruli: Enter in the number of visualized globally sclerotic glomeruli. The number must fall between 0–300. If unavailable, select the reason from the status (ST) drop-down list (N/A, Not Done, Missing, Unknown).
Nodular mesangial glomerulosclerosis:
Absent
Present
Unknown
Interstitial fibrosis/tubular atrophy (IFTA): Enter the amount of interstitial fibrosis/tubular atrophy (IFTA).
≤5%
6-25%
26-50%
>50%
Unknown
Vascular disease (% luminal narrowing): Enter the amount of vascular change.hya
None (<10%)
Mild (10-25%)
Moderate (26-50%)
Severe (>50%)
Unknown
Arteriolar hyalinosis: This field is required.
None
Mild to moderate (1 arteriole)
Moderate to severe (>1 arteriole)
Severe – multiple or circumferential
Unknown
Cortical necrosis: This field is required.
Present
Absent
Unknown
% Cortical necrosis: If cortical necrosis is present, indicate the % cortical necrosis. This field is required.
Fibrin thrombi: This field is required.
Present
Absent
Unknown
% Fibrin thrombi: If fibrin thrombi are present, indicate the % fibrin thrombi. This field is required.
Left kidney comments: Enter any comments concerning the kidney.
Right Kidney
Right kidney biopsy: Indicate if a biopsy was performed on the right kidney. Only a Yes value copies over to the TIEDI DDR record.
Yes
No
% Glomerulosclerosis: Enter the value for the right kidney. This data copies over to the TIEDI DDR record.
Range: 0–99
Biopsy type: Select the biopsy type for the right kidney from the drop-down list.
Needle
Wedge
Number of Glomeruli: Enter the count.
Range: 0–300
Right Kidney Pump Values:
Pump Date: Enter the date (MM/DD/YYYY) the right kidney pump values were obtained. A calendar link is available.
Pump Time: Enter the time (HH:MM) the right kidney pump values were obtained.
Note: Time should be in 24-hour format.
Flow (cc/min): Enter the flow value for the right kidney pump in cc/min.
Pressure (mmHg) – Systolic: Enter the systolic pressure value for the right kidney pump in mmHg.
Range: 0–300
Pressure (mmHg) – Diastolic: Enter the diastolic pressure value for the right kidney pump in mmHg.
Range: 0–200
Resistance: Enter the resistance value for the right kidney pump.
Right kidney pump device: Select the right kidney pump device. If Other, specify is selected, enter the device type in the space provided.
ORS: LifePort
Waters: RM3
Waters: Waves
Other, specify
Right kidney pump solution: Select the right kidney pump solution. If Other, specify is selected, enter the solution in the space provided.
Belzer
Silica gel
Other, specify
Tissue preparation technique: This field is required.
Frozen section
FPPE section
Unknown
Number of globally sclerotic glomeruli: Enter in the number of visualized globally sclerotic glomeruli. The number must fall between 0–300. If unavailable, select the reason from the status (ST) drop-down list (N/A, Not Done, Missing, Unknown).
Nodular mesangial glomerulosclerosis:
Absent
Present
Unknown
Interstitial fibrosis/tubular atrophy (IFTA): Enter the amount of interstitial fibrosis/tubular atrophy (IFTA).
≤5%
6-25%
26-50%
>50%
Unknown
Vascular disease (% luminal narrowing): Enter the amount of vascular change.hya
None (<10%)
Mild (10-25%)
Moderate (26-50%)
Severe (>50%)
Unknown
Arteriolar hyalinosis: This field is required.
None
Mild to moderate (1 arteriole)
Moderate to severe (>1 arteriole)
Severe – multiple or circumferential
Unknown
Cortical necrosis: This field is required.
Present
Absent
Unknown
% Cortical necrosis: If cortical necrosis is present, indicate the % cortical necrosis. This field is required.
Fibrin thrombi: This field is required.
Present
Absent
Unknown
% Fibrin thrombi: If fibrin thrombi are present, indicate the % fibrin thrombi. This field is required.
Right kidney comments: Enter any comments concerning the kidney.
Pancreas
Pancreas comments: Enter any comments concerning the pancreas.
Liver
Liver Biopsy: If a biopsy was performed to evaluate organ histology for assessing organ function/quality of the liver, select Yes. If no biopsy was performed, select No. If a biopsy was performed only for other reasons, for example to evaluate a potentially cancerous lesion, select No. Only a Yes value copies over to the TIEDI DDR record.
Yes
No
Macrosteatosis %: If Yes is selected for Liver Biopsy, enter the percentage of macrosteatosis. The value must be between 0 and 100. This is not a required field, but should be used if liver biopsy is available at the time of offer as this will assist in screening criteria. This data field will cascade to the DDR for the appropriate data collection field. The data reported for Macrosteatosis % in DonorNet will cascade to the DDR form field.
Liver Biopsy comments: Enter any comments concerning the biopsy. This field is required.
Liver comments: Enter any comments concerning the liver.
Intestine
Intestine comments: Enter any comments concerning the liver/intestine.
Heart
LV ejection fraction (%): Enter the left ventricular ejection fraction value (%). This data copies over to the TIEDI DDR record. This is a required field.
Definition: The ratio of the volume of blood the heart empties during systole to the volume of blood in the heart at the end of diastole expressed as a percentage usually between 50 and 80 percent.
Range: 1–99
Method: Select the type of left ventricular ejection method from the drop-down list. This data copies over to the TIEDI DDR record.
Echo
MUGA
Angiogram
Note: If no LV ejection fraction value is available, OPOs will be permitted to enter Shortening Fraction instead in order to send heart and heart-lung electronic organ offers from pediatric donors (under the age of 18).
Shortening fraction (SF): Enter value (%).
Range: 0–50
Note: If no LV ejection fraction value is available, OPOs will be permitted to enter Shortening Fraction instead in order to send heart and heart-lung electronic organ offers from pediatric donors (under the age of 18).
Septal wall thickness (cm): Enter the Septal wall thickness in cm.
Range: 0.1–3.5 cm.
LV posterior wall thickness (cm): Enter the LV posterior wall thickness in cm.
Range: 0.1–3.5 cm.
Heart comments: Heart comments: Enter any comments concerning the heart.
Lungs
Date intubated: Enter the date of intubation. A calendar link is available.
Format: MM/DD/YYYY
Time intubated: Enter the time of intubation.
Format: HH:MM
Note: Time should be in 24-hour format
Lungs Measurements:
Length of left lung (cm): Enter the length of the left lung in cm.
Range: 0–200 cm.
Length of right lung (cm): Enter the length of the right lung in cm.
Range: 0–200 cm.
Aortic knob width (cm): Enter the width of the aortic knob in cm.
Range: 0–200 cm.
Diaphragm width (cm): Enter the width of the diaphragm in cm.
Range: 0–200 cm.
Chest circ. / landmark (cm): Enter the Chest circumference / landmark in cm.
Range: 0–999 cm.
Dist. RCPA to LCPA (cm): Enter the distance RCPA to LCPA in cm.
Range: 0–999 cm.
Chest X-ray: Indicate whether abnormalities were found on the chest x-ray. This data (excluding No chest x-ray, Results Unknown, and Unknown if chest x-ray performed) copies over to the TIEDI DDR record.
No chest x-ray
Normal
Abnormal-left
Abnormal-right
Abnormal-both
Results Unknown
Unknown if chest x-ray performed
Left lung comments: Enter any comments concerning the left lung.
Right lung comments: Enter any comments concerning the right lung.
VCA organs comments: Enter any comments concerning VCA organs.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Lyna Cherikh |
| File Modified | 0000-00-00 |
| File Created | 2023-10-26 |