66 Death Notification Registration

Death Notification Registration
Fields to be completed by members
Form Section	Field Label	Notes
Death Notification Registration	Status
Death Notification Registration	Donor ID
Death Notification Registration	OPO	Display only - Cascades from database unless referral only and no Donor ID exists
Death Notification Registration	Donor hospital	Display only - Cascades from database unless referral only and no Donor ID exists
Death Notification Registration	OPO record ID	Display only - Cascades from database unless referral only and no Donor ID exists
Death Notification Registration	Recovery date (donor to OR)	Display only - Cascades from database unless referral only and no Donor ID exists
Death Notification Registration	Date & time of pronouncement of death:	Display only - Cascades from database unless referral only and no Donor ID exists
Death Notification Registration	Date of referral or death record review
Death Notification Registration	How did you learn of this case?
Death Notification Registration	Referral classification
Death Notification Registration	Did the patient legally document their decision to be a donor?
Death Notification Registration	Has authorization been obtained for organ donation?
Death Notification Registration	Method of authorization used
Death Notification Registration	Select the reason organ donation was not obtained
Death Notification Registration	Did the OPO notify the medical examiner/coroner?
Death Notification Registration	Did the medical/coroner accept the case?
Death Notification Registration	Were there any restrictions?
Death Notification Registration	Organ Restrictions
Death Notification Registration	Last name
Death Notification Registration	First name
Death Notification Registration	Gender
Death Notification Registration	Age
Death Notification Registration	Patient's home zipcode
Death Notification Registration	Ethnicity
Death Notification Registration	Race
Death Notification Registration	Cause of death
Death Notification Registration	Specify:
Death Notification Registration	Mechanism of death
Death Notification Registration	Circumstances of death
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].