Deceased Donor Death Referral

OMB No. 0915-0157; Expiration Date: XX/XX/202X

Deceased Donor Death Referral

Monthly Donation Data Report

Provider ID: Hospital’s provider ID. This field is read-only.

Hospital name: Donor hospital name. This field is read-only.

Reported deaths: All deaths or imminent deaths (ventilated and non-ventilated) reported by a hospital to the OPO, tissue or eye bank located within the OPO service area.

Eligible deaths: This field is read-only. The value is calculated from information provided on the individual Death Notification Registration (DNR) forms.

Authorized eligible deaths: All reported deaths which met the eligible death requirements and where authorization was obtained for donation.

Imminent deaths: This field is read-only. The value is calculated from information provided on the individual Death Notification Registration (DNR) forms.

Donors: This field is read-only. A total number of deceased patients who were reported to have had one or more organs recovered for transplantation from the specified donor hospital. This information is obtained from the completed Donor Organ Disposition (Feedback) form.

Organs recovered/transplanted: This field is read-only. The number of organs that were reported as recovered and transplanted from the specified donor hospital. This information is obtained from the donor record and Donor Organ Disposition (Feedback) form.

Donation Data Confirmation Report

Month: Click on the name of the month to view or edit the report.

Reported deaths: All deaths or imminent deaths (ventilated and non-ventilated) reported by a hospital to the OPO, tissue or eye bank located within the OPO service area.

Eligible deaths: This field is read-only. The value is calculated from information provided on the individual Death Notification Registration (DNR) forms.

Authorized eligible deaths: All reported deaths which met the eligible death requirements and where authorization was obtained for donation.

Imminent deaths: This field is read-only. The value is calculated from information provided on the individual Death Notification Registration (DNR) forms.

Confirmed by: Enter your name to indicate that you have carefully reviewed the information in this report and have found its contents to be both accurate and true. This field is required.

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].   

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