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 | |
Removing this from documentation as it is a duplicate of row 21 above | ||
Match Results | Intestine placed | |
Match Results | AVCA - abdominal wall placed | Display only |
Match Results | EVCA - external male genitalia placed | |
Match Results | HVCA - head and neck placed | |
Match Results | LVCA - lower limb(s) placed | |
Match Results | MVCA - musculoskeletal composite graft segment(s) placed | |
Match Results | OVCA - other genitourinary organ(s) placed | |
Match Results | SVCA - spleen placed | Display only |
Match Results | UVCA - upper limb placed | |
Match Results | UVCA - uterus placed | Display only |
Match Results | VCA - vascularized gland(s) placed | |
Removing this from documentation; not enterred by external members; UNOS staff only field | ||
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 ResultsVerify Organ Offer Info - Update Offer |
Primary TXC bypass code | (Updated documention to reflect data collected on Match Results form section) |
Match ResultsVerify Organ Offer Info - Update Offer |
Primary Bbypass Code - Sspecify Other | (Updated documention to reflect data collected on Match Results form section) |
Match ResultsVerify Organ Offer Info - Update Offer |
Secondary TXC bypass code | (Updated documention to reflect data collected on Match Results form section) |
Match ResultsVerify Organ Offer Info - Update Offer |
Secondary Bbypass Code - Sspecify Other | (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]. | ||
File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |