65 Potential Transplant Recipient

Potential Transplant Recipient
Fields to be completed by members
Form Section	Field Label	Notes
Match Results	Transplant center contacted?
Match Results	Contact last name
Match Results	Contact first name
Match Results	Respond date
Match Results	Respond time
Match Results	Respond time zone
Match Results	Offer response
Match Results	Primary refusal reason
Match Results	Primary specify
Match Results	Secondary refusal reason
Match Results	Secondary specify
Match Results	Lung(s) placed
Match Results	Segment(s) placed	Applies to lung only
Match Results	Heart placed	Display only
Match Results	Heart/Lung placed
Match Results	Liver placed
Match Results	Pancreas placed
Match Results	Kidney placed
Match Results	Intestine placed
Match Results	VCA - abdominal wall placed	Display only
Match Results	VCA - external male genitalia placed
Match Results	VCA - head and neck placed
Match Results	VCA - lower limb(s) placed
Match Results	VCA - musculoskeletal composite graft segment(s) placed
Match Results	VCA - other genitourinary organ(s) placed
Match Results	VCA - spleen placed	Display only
Match Results	VCA - upper limb placed
Match Results	VCA - uterus placed	Display only
Match Results	VCA - vascularized gland(s) placed
Verify Organ Offer Info - Update Offer	Primary TXC refusal code
Verify Organ Offer Info - Update Offer	Primary Refusal Code - Specify Other
Verify Organ Offer Info - Update Offer	Secondary TXC refusal code
Verify Organ Offer Info - Update Offer	Secondary Refusal Code - Specify Other
Match Results	Primary bypass code	Updated documention to reflect data collected on Match Results form section
Match Results	Primary bypass - specify	Updated documention to reflect data collected on Match Results form section
Match Results	Secondary bypass code	Updated documention to reflect data collected on Match Results form section
Match Results	Secondary bypass - specify	Updated documention to reflect data collected on Match Results form section
OMB No. 0915-0157; Expiration Date: XX/XX/20XX
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 Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected].