63 Initial Donor Registration

	Initial Donor Registration Fields to be completed by members
	Form Section	Field Label	Notes
	Details	Donor Id	Display only - Calculated
	Details	OPO
	Details	Donor hospital
	Details	Time zone
	Details	Is Daylight Savings Time observed?
	Details	Last Name
	Details	First Name
	Details	Middle Initial
	Details	KDPI	Display only - Calculated
	Details	ABO
	Details	Date of birth
	Details	Age (Value)
	Details	Age (Unit)
	Details	Height (ft)
	Details	Height (in)
	Details	Height (cm)
	Details	Weight (lbs)
	Details	Weight (kgs)
	Details	BMI	Display only - Calculated
	Details	Cause of death
	Details	Cause of death - Specify
	Details	Admit date
	Details	time
	Details	Mechanism of injury
	Details	Pronouncement of death date
	Details	time
	Details	Circumstance of death
	Details	Cold ischemic type	Display only - Calculated
	Details	OR Date (status)
	Details	OR Date (date)
	Details	OR Date (time)
	Details	Recovery Facility
	Details	Recovery Facility (Alternate Facility Text)
	Details	Donor meets DCD criteria
	Details	Cardiac arrest / downtime?
	Details	Cardiac arrest / downtime duration (min)
	Details	CPR administered?
	Details	CPR duration (min)
	Details	Ethnicity
	Details	Race
	Details	Donor Highlights
	Details	Admission course comments
	Details	History of diabetes
	Details	History of cancer
	Details	History of cancer, specify
	Details	History of hypertension
	Details	Compliant with treatment
	Details	History of coronary artery disease (CAD)
	Details	Previous gastrointestinal disease
	Details	Chest trauma
	Details	Cigarette use (>20 pack years) ever
	Details	And continued in last six months
	Details	Heavy alcohol use (2+ drinks/day)
	Details	I.V. drug usage
	Details	According to the OPTN policy in effect on the date of referral, does the donor have risk factors for blood-borne disease transmission:	Display only - Calculated
	Details	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
	Details	Man who has had sex with another man
	Details	Sex in exchange for money or drugs
	Details	Sex with a person who had sex in exchange for money or drugs
	Details	Drug injection for nonmedical reasons
	Details	Sex with a person who injected drugs for nonmedical reasons
	Details	Incarceration (confinement in jail, prison, or juvenile correction facility) for ≥72 consecutive hours
	Details	Child breastfed by a mother with HIV infection
	Details	Child born to a mother with HIV, HBV, or HCV infection
	Details	Unknown medical or social history
	Details	History of myocardial infarction
	Details	Medical and social history comments
	Vital Signs	Begin Date
	Vital Signs	Begin Time
	Vital Signs	End Date
	Vital Signs	End Time
	Vital Signs	Average or Actual BP - Systolic
	Vital Signs	Average or Actual BP - Diastolic
	Vital Signs	Heart Rate - Low (bpm)
	Vital Signs	Heart Rate - High (bpm)
	Vital Signs	High Blood Pressure - Systolic
	Vital Signs	High Blood Pressure - Diastolic
	Vital Signs	Duration at high (minutes)
	Vital Signs	Low Blood Pressure - Systolic
	Vital Signs	Low Blood Pressure - Diastolic
	Vital Signs	Duration at low (minutes)
	Vital Signs	Core Body Temp - Low
	Vital Signs	Core Body Temp - High
	Vital Signs	Core Body Temp - Unit
	Vital Signs	Urine output (cc/hour) - Low
	Vital Signs	Urine output (cc/hour) - High
	Vital Signs	CVP - Low (mm/Hg)
	Vital Signs	CVP - High (mm/Hg)
	Vital Signs	PA Pressure - Systolic - Low (mm/Hg)
	Vital Signs	PA Pressure - Systolic - High (mm/Hg)
	Vital Signs	PA Pressure - Diastolic - Low (mm/Hg)
	Vital Signs	PA Pressure - Diastolic - High (mm/Hg)
	Vital Signs	PCWP - Low (mm/Hg)
	Vital Signs	PCWP - High (mm/Hg)
	Vital Signs	PAMP - Low (mm/Hg)
	Vital Signs	PAMP - High (mm/Hg)
	Vital Signs	Cardiac Output - Low (L/min)
	Vital Signs	Cardiac Output - High (L/min)
	Vital Signs	Cardiac Input - Low (L/min/sq. m)
	Vital Signs	Cardiac Input - High (L/min/sq. m)
	Vital Signs	Date
	Vital Signs	Time
	Vital Signs	Average or Actual BP - Systolic
	Vital Signs	Average or Actual BP - Diastolic
	Vital Signs	Heart Rate (bpm)
	Vital Signs	Core Body Temp (Value)
	Vital Signs	Core Body Temp (Unit)
	Vital Signs	Urine output (cc/hr)
	Vital Signs	CVP (mm/Hg)
	Vital Signs	PA Pressure - Systolic (mm/Hg)
	Vital Signs	PA Pressure - Diastolic (mm/Hg)
	Vital Signs	PCWP (mm/Hg)
	Vital Signs	PAMP (mm/Hg)
	Vital Signs	Cardiac Output (L/min)
	Vital Signs	Cardiac Input (L/min/sq.m)
	Vital Signs	Vital Signs Comments
	Labs	Date
	Labs	Time
	Labs	WBC (thous/mcL)
	Labs	RBC (mill/mcL)
	Labs	HgB (g/dL)
	Labs	Hct (%)
	Labs	Plt (thous/mcL)
	Labs	Bands (%)
	Labs	Date
	Labs	Time
	Labs	Serum Sodium (mEg/L)
	Labs	K+ (mmol/L)
	Labs	Cl (mmol/L)
	Labs	CO2 (mmol/L)
	Labs	BUN (mg/dL)
	Labs	Creatinine (mg/dL)
	Labs	Glucose (mg/dL)
	Labs	Total Bilirubin (mg/dL)
	Labs	Direct Bilirubin (mg/dL)
	Labs	Indirect Bilirubin (mg/dL)
	Labs	SGOT (AST) (u/L)
	Labs	SGPT (ALT) (u/L)
	Labs	Alkaline phosphatase (u/L)
	Labs	GGT (u/L)
	Labs	LDH (u/L)
	Labs	Albumin (g/dL)
	Labs	Total protein (g/dL)
	Labs	Prothrombin (PT) (seconds)
	Labs	INR
	Labs	PTT (seconds)
	Labs	Serum Amylase (u/L)
	Labs	Serum Lipase (u/L)
	Labs	Serum Lipase Upper Normal Limit (u/L)
	Labs	Date
	Labs	Time
	Labs	Color
	Labs	Appearance
	Labs	pH
	Labs	Specific gravity
	Labs	Protein
	Labs	Protein - Specify
	Labs	Glucose
	Labs	Glucose - Specify
	Labs	Blood
	Labs	Blood - Specify
	Labs	RBC
	Labs	RBC - Specify
	Labs	WBC
	Labs	WBC - Specify
	Labs	Epith (%)
	Labs	Epith (%) - Specify
	Labs	Casts
	Labs	Casts - Specify
	Labs	Bacteria
	Labs	Bacteria - Specify
	Labs	Leukocyte esterase
	Labs	Leukocyte esterase - Specify
	Labs	Date
	Labs	Time
	Labs	pH
	Labs	PaCO2 (mmHg)
	Labs	PaO2 (mmHg)
	Labs	HCO3 (mEq/L)
	Labs	SaO2 (%)
	Labs	Mode
	Labs	Mode - Specify
	Labs	FiO2 (%)
	Labs	RR
	Labs	Vt (cc)
	Labs	PEEP (cmH2O)
	Labs	Date
	Labs	Time
	Labs	CPK (u/L)
	Labs	CK-MB (ng/mL)
	Labs	Troponin I (ng/mL)
	Labs	Troponin T (ng/mL)
	Labs	Toxicology Screen
	Labs	Toxicology Screen - Results
	Labs	HbA1c (%) - Value
	Labs	HbA1c (%) - Date
	Labs	HbA1C (%) - Time
	Labs	Other labs - Specify
	Labs	Date
	Labs	Time
	Labs	Type
	Labs	Type - Specify
	Labs	Result
	Labs	Comments
	Meds/Fluids	Inotropic Medication
	Meds/Fluids	Inotropic Medication - Specify
	Meds/Fluids	Begin Date
	Meds/Fluids	Begin Time
	Meds/Fluids	End Date
	Meds/Fluids	End Time
	Meds/Fluids	Value
	Meds/Fluids	Units
	Meds/Fluids	I.V. fluids (cc/hour)
	Meds/Fluids	Is there dextrose in I.V. fluids?
	Meds/Fluids	Steroids
	Meds/Fluids	Steroids - Specify
	Meds/Fluids	Diuretics
	Meds/Fluids	Diuretics - Specify
	Meds/Fluids	T3
	Meds/Fluids	T4
	Meds/Fluids	Insulin
	Meds/Fluids	Insulin - Begin Date
	Meds/Fluids	Insulin - Begin Time
	Meds/Fluids	Insulin - End Date
	Meds/Fluids	Insulin - End Time
	Meds/Fluids	Antihypertensives
	Meds/Fluids	Vasodilators
	Meds/Fluids	Vasodilators - Begin Date
	Meds/Fluids	Vasodilators - Begin Time
	Meds/Fluids	Vasodilators - End Date
	Meds/Fluids	Vasodilators - End Time
	Meds/Fluids	DDAVP
	Meds/Fluids	Arginine vasopressin
	Meds/Fluids	Arginine vasopressin - Begin Date
	Meds/Fluids	Arginine vasopressin - Begin Time
	Meds/Fluids	Arginine vasopressin - End Date
	Meds/Fluids	Arginine vasopressin - End Time
	Meds/Fluids	Total Parenteral Nutrition
	Meds/Fluids	Heparin
	Meds/Fluids	Heparin - Begin Date
	Meds/Fluids	Heparin - Begin Time
	Meds/Fluids	Heparin - End Date
	Meds/Fluids	Heparin - End Time
	Meds/Fluids	Heparin - Units
	Meds/Fluids	Other/specify 1
	Meds/Fluids	Other/specify 2
	Meds/Fluids	Other/specify 3
	Meds/Fluids	Transfusions prior to ABO determination
	Meds/Fluids	Total number
	Meds/Fluids	Total volume
	Meds/Fluids	Transfusions following ABO determination
	Meds/Fluids	Total number
	Meds/Fluids	Total volume
	Meds/Fluids	Other blood products
	Meds/Fluids	Other blood products - Specify
	Infectious Diseases	Anti-HBc
	Infectious Diseases	Anti-HBc - Hemodilution
	Infectious Diseases	HBV NAT
	Infectious Diseases	HBV NAT - Hemodilution
	Infectious Diseases	HBsAg
	Infectious Diseases	HBsAg - Hemodilution
	Infectious Diseases	HBsAb
	Infectious Diseases	HBsAb - Hemodilution
	Infectious Diseases	Anti-HCV
	Infectious Diseases	Anti-HCV - Hemodilution
	Infectious Diseases	HCV NAT
	Infectious Diseases	HCV NAT - Hemodilution
	Infectious Diseases	Anti-HIV I/II
	Infectious Diseases	Anti-HIV I/II - Hemodilution
	Infectious Diseases	HIV Ag/Ab Combo
	Infectious Diseases	HIV Ag/Ab Combo - Hemodilution
	Infectious Diseases	HIV NAT
	Infectious Diseases	HIV NAT - Hemodilution
	Infectious Diseases	Anti-HTLV I/II
	Infectious Diseases	Anti-HTLV I/II - Hemodilution
	Infectious Diseases	HTLV NAT
	Infectious Diseases	HTLV NAT - Hemodilution
	Infectious Diseases	Anti-CMV
	Infectious Diseases	Anti-CMV - Hemodilution
	Infectious Diseases	Syphilis
	Infectious Diseases	Syphilis - Hemodilution
	Infectious Diseases	EBV (VCA) (IgG)
	Infectious Diseases	EBV (VCA) (IgG) - Hemodilution
	Infectious Diseases	EBV (VCA) (IgM)
	Infectious Diseases	EBV (VCA) (IgM) - Hemodilution
	Infectious Diseases	EBNA
	Infectious Diseases	EBNA - Hemodilution
	Infectious Diseases	Toxoplasma (IgG)
	Infectious Diseases	Toxoplasma (IgG) - Hemodilution
	Infectious Diseases	Chagas
	Infectious Diseases	Chagas - Hemodilution
	Infectious Diseases	Chagas NAT
	Infectious Diseases	Chagas NAT - Hemodilution
	Infectious Diseases	West Nile
	Infectious Diseases	West Nile - Hemodilution
	Infectious Diseases	West Nile NAT
	Infectious Diseases	West Nile NAT - Hemodilution
	Infectious Diseases	Strongyloides
	Infectious Diseases	Strongyloides - Hemodilution
	Infectious Diseases	Was COVID-19 (SARS-CoV-2) testing performed on the donor?
	Infectious Diseases	Specimen Date
	Infectious Diseases	Specimen Time
	Infectious Diseases	Specimen Type
	Infectious Diseases	Specimen Type - Specify
	Infectious Diseases	Hemodiluted Specimen
	Infectious Diseases	Test Method
	Infectious Diseases	Test Method - Specify
	Infectious Diseases	Result
	Infectious Diseases	Comments
	Tests	Test Type
	Tests	Test Type - Specify
	Tests	Test Date
	Tests	Test Time
	Tests	Diagnostic evaluation/comments
	Tests	Attach medical image
	Tests	Attachment Description
	Tests	Attachment File
	Tests	Study
	Attachments	Attachment Description
	Attachments	Attachment File
	Attachments	Attachment Category
	Crossmatch & HLA	A1
	Crossmatch & HLA	A2
	Crossmatch & HLA	B1
	Crossmatch & HLA	B2
	Crossmatch & HLA	BW4
	Crossmatch & HLA	BW6
	Crossmatch & HLA	C1
	Crossmatch & HLA	C2
	Crossmatch & HLA	DR1
	Crossmatch & HLA	DR2
	Crossmatch & HLA	DR51
	Crossmatch & HLA	DR51_2
	Crossmatch & HLA	DR52
	Crossmatch & HLA	DR52_2
	Crossmatch & HLA	DR53
	Crossmatch & HLA	DR53_2
	Crossmatch & HLA	DQB1
	Crossmatch & HLA	DQB1_2
	Crossmatch & HLA	DQA1
	Crossmatch & HLA	DQA1_2
	Crossmatch & HLA	DPB1
	Crossmatch & HLA	DPB1_2
	Crossmatch & HLA	DPA1
	Crossmatch & HLA	DPA1_2
	Crossmatch & HLA	Is there time for a preliminary crossmatch
	Organ Data	Warm ischemic time (minutes)
	Organ Data	Left kidney biopsy
	Organ Data	% Global glomerulosclerosis	Read only - calculated
	Organ Data	Biopsy type
	Organ Data	Number of glomeruli
	Organ Data	Pump Date
	Organ Data	Pump Time
	Organ Data	Flow (cc/min)
	Organ Data	Pressure (mmHg) - Systolic
	Organ Data	Pressure (mmHg) - Diastolic
	Organ Data	Resistance
	Organ Data	Left kidney pump device
	Organ Data	Left kidney pump device - Specify
	Organ Data	Left kidney pump solution
	Organ Data	Left kidney pump solution - Specify
	Organ Data	Left kidney tissue preparation technique
	Organ Data	Left kidney number of globally sclerotic glomeruli
	Organ Data	Left kidney nodular mesangial glomerulosclerosis
	Organ Data	Left kidney interstitial fibrosis/tubular atrophy (IFTA)
	Organ Data	Left kidney vascular disease (% luminal narrowing)
	Organ Data	Left kidney arteriolar hyalinosis
	Organ Data	Left kidney cortical Necrosis
	Organ Data	Left kidney % Cortical Necrosis
	Organ Data	Left kidney Fibrin thrombi
	Organ Data	Left kidney % Fibrin thrombi
	Organ Data	Left kidney comments
	Organ Data	Right kidney biopsy
	Organ Data	% Global glomerulosclerosis	Read only - calculated
	Organ Data	Biopsy type
	Organ Data	Number of glomeruli
	Organ Data	Pump Date
	Organ Data	Pump Time
	Organ Data	Flow (cc/min)
	Organ Data	Pressure (mmHg) - Systolic
	Organ Data	Pressure (mmHg) - Diastolic
	Organ Data	Resistance
	Organ Data	Right kidney pump device
	Organ Data	Right kidney pump device - Specify
	Organ Data	Right kidney pump solution
	Organ Data	Right kidney pump solution - Specify
	Organ Data	Right kidney tissue preparation technique
	Organ Data	Right kidney number of globally sclerotic glomeruli
	Organ Data	Right kidney nodular mesangial glomerulosclerosis
	Organ Data	Right kidney interstitial fibrosis/tubular atrophy (IFTA)
	Organ Data	Right kidney vascular disease (% luminal narrowing)
	Organ Data	Right kidney arteriolar hyalinosis
	Organ Data	Right kidney cortical Necrosis
	Organ Data	Right kidney % Cortical Necrosis
	Organ Data	Right kidney Fibrin thrombi
	Organ Data	Right kidney % Fibrin thrombi
	Organ Data	Right kidney comments
	Organ Data	Pancreas comments
	Organ Data	Liver Biopsy
	Organ Data	Macrosteatosis %
	Organ Data	Liver Biopsy comments
	Organ Data	Liver Comments
	Organ Data	Intestine comments
	Organ Data	LV ejection fraction (%)
	Organ Data	Method
	Organ Data	Shortening fraction (SF) (%)
	Organ Data	Septal wall thickness (cm)
	Organ Data	LV posterior wall thickness (cm)
	Organ Data	Heart comments
	Organ Data	Date intubated
	Organ Data	Time intubated
	Organ Data	Length of left lung (cm)
	Organ Data	Length of right lung (cm)
	Organ Data	Aortic knob width (cm)
	Organ Data	Diaphragm width (cm)
	Organ Data	Chest circ./landmark (cm)
	Organ Data	Dist. RCPA to LCPA (cm)
	Organ Data	Chest X-ray
	Organ Data	Left lung comments
	Organ Data	Right lung comments
	Organ Data	VCA organs comments
	Verify ABO	ABO
	Verify ABO Subtype	ABO
	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].