Form 72 Pediatric Kidney Candidate Listing Registration Form

Pediatric Kidney Candidate Listing Registration
Fields to be completed by members
Form Section	Field Label	Notes
Provider	Transplant Hospital	Display Only – Cascades from Database
Provider	24 Hour Contact Phone Number
Organ Registration	Organ registration	Display Only – Cascades from Database
Candidate Identification	SSN
Candidate Identification	Confirm SSN
Candidate Identification	Date of birth
Candidate Identification	Confirm date of birth
Candidate Identification	Center patient ID
Demographic Information	Last name
Demographic Information	First name
Demographic Information	MI
Demographic Information	Birth sex
Demographic Information	State of permanent residence
Demographic Information	Permanent ZIP code
Demographic Information	Ethnicity
Demographic Information	Race
Kidney Organ Information	Candidate medical urgency status
Kidney Organ Information	Inactive reason
Kidney Organ Information	Number of previous kidney transplants
Kidney Organ Information	Number of previous solid organ transplants from OPTN database	Display Only - Cascades from database
Kidney Organ Information	Number of previous solid organ transplants
Kidney Organ Information	Vascular access in the upper left extremity
Kidney Organ Information	Vascular access in the upper right extremity
Kidney Organ Information	Vascular access in the lower left extremity
Kidney Organ Information	Vascular access in the lower right extremity
Kidney Organ Information	Peritoneal access in the abdomen
Kidney Organ Information	Transhepatic IVC catheter
Kidney Organ Information	Translumbar IVC catheter
Kidney Organ Information	Other (must specify)
Kidney Organ Information	Other (must specify) (Text Field)
Kidney Organ Information	Nephrologist full name
Kidney Organ Information	Nephrologist NPI
Kidney Organ Information	Surgeon full name
Kidney Organ Information	Surgeon NPI
Clinical Information	Blood type
Clinical Information	Height (cm)
Clinical Information	Height (ft)
Clinical Information	Height (in)
Clinical Information	Weight (kg)
Clinical Information	Weight (lbs)
Clinical Information	Creatinine clearance (measured or estimated) level less than or equal to 20 mL/min?
Clinical Information	Creatinine clearance (measured or estimated) level for waiting time qualification
Clinical Information	Date of qualifying test
Clinical Information	GFR (measured or estimated) less than or equal to 20 mL/min?
Clinical Information	GFR (measured or estimated) for waiting time qualification
Clinical Information	Date of qualifying test
Clinical Information	Has the candidate had regularly administered dialysis for ESRD?
Clinical Information	Date of initiation of regularly administered dialysis for ESRD
Clinical Information	Physician name
Clinical Information	Physician NPI
Clinical Information	Current diabetes status
A2/A2B Eligibility	Does candidate meet criteria for A2/A2B (including patient consent)?
Priority for Liver Transplants Recipient on Kidney Match	Status of candidate's priority on kidney match as liver recipient	Display Only – Cascades from Database
Priority for Liver Transplants Recipient on Kidney Match	Most recent liver transplant date	Display Only - Cascades from database
Priority for Liver Transplants Recipient on Kidney Match	Eligibility will expire if qualifying data is not entered by	Display Only - Cascades from database
Priority for Liver Transplants Recipient on Kidney Match	Number of consecutive days candidate has been eligible for priority	Display Only - Cascades from database
Priority for Liver Transplants Recipient on Kidney Match	Date of test or treatment
Priority for Liver Transplants Recipient on Kidney Match	On dialysis?
Priority for Liver Transplants Recipient on Kidney Match	CrCl (measured or estimated) (mL/min)
Priority for Liver Transplants Recipient on Kidney Match	GFR (measured or estimated) (mL/min)
Priority for Liver Transplants Recipient on Kidney Match	Medical Criteria (five most recent tests or treatments displayed below)
Additional Organs	Check any additional organs the candidate may need
HLA CLASS I	A
HLA CLASS I	A
HLA CLASS I	B
HLA CLASS I	B
HLA CLASS I	BW4
HLA CLASS I	BW6
HLA CLASS I	C
HLA CLASS I	C
HLA CLASS II	DR
HLA CLASS II	DR
HLA CLASS II	DR51
HLA CLASS II	DR51
HLA CLASS II	DR52
HLA CLASS II	DR52
HLA CLASS II	DR53
HLA CLASS II	DR53
HLA CLASS II	DQB1
HLA CLASS II	DQB1
HLA CLASS II	DQA1
HLA CLASS II	DQA1
HLA CLASS II	DPB1
HLA CLASS II	DPB1
HLA CLASS II	DPA1
HLA CLASS II	DPA1
Confirm HLA CLASS I	A
Confirm HLA CLASS I	A
Confirm HLA CLASS I	B
Confirm HLA CLASS I	B
Confirm HLA CLASS I	BW4
Confirm HLA CLASS I	BW6
Confirm HLA CLASS I	C
Confirm HLA CLASS I	C
Confirm HLA CLASS II	DR
Confirm HLA CLASS II	DR
Confirm HLA CLASS II	DR51
Confirm HLA CLASS II	DR51
Confirm HLA CLASS II	DR52
Confirm HLA CLASS II	DR52
Confirm HLA CLASS II	DR53
Confirm HLA CLASS II	DR53
Confirm HLA CLASS II	DQB1
Confirm HLA CLASS II	DQB1
Confirm HLA CLASS II	DQA1
Confirm HLA CLASS II	DQA1
Confirm HLA CLASS II	DPB1
Confirm HLA CLASS II	DPB1
Confirm HLA CLASS II	DPA1
Confirm HLA CLASS II	DPA1
HLA	Tested for anti-HLA antibodies?
Unacceptable Antigens	A
Unacceptable Antigens	B
Unacceptable Antigens	BW
Unacceptable Antigens	C
Unacceptable Antigens	DR
Unacceptable Antigens	DR51
Unacceptable Antigens	DR52
Unacceptable Antigens	DR53
Unacceptable Antigens	DQB1
Unacceptable Antigens	DQA1
Unacceptable Antigens	DPB1 - Unacceptable antigens
Unacceptable Antigens	DPB1 - Unacceptable epitopes
Unacceptable Antigens	DPA1
Offer filters	Apply/Do not apply kidney offers for this patient
Candidate and Donor Characteristics	Maximum acceptable number of HLA mismatches
Candidate and Donor Characteristics	AB
Candidate and Donor Characteristics	ABDR
Candidate and Donor Characteristics	BDR
Candidate and Donor Characteristics	A
Candidate and Donor Characteristics	B
Candidate and Donor Characteristics	DR
Dual Kidney and En Bloc Opt In	Accept dual kidney (local)?
Dual Kidney and En Bloc Opt In	Accept dual kidney (import)?
Dual Kidney and En Bloc Opt In	Accept en bloc kidney? (local)
Dual Kidney and En Bloc Opt In	Accept en bloc kidney? (import)
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI) (local) 0 ABDR mismatch
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI) (import) 0 ABDR mismatch
Donor Characteristics	Single Kidney Maximum acceptable Kidney Donor Profile Index (KDPI) (local) Non-0 ABDR mismatch
Donor Characteristics	Single Kidney Maximum acceptable Kidney Donor Profile Index (KDPI) (import) Non-0 ABDR mismatch
Donor Characteristics	Dual Kidney Maximum acceptable Kidney Donor Profile Index (KDPI) (local) 0 ABDR mismatch
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI) (import) 0 ABDR mismatch
Donor Characteristics	Dual Kidney Maximum acceptable Kidney Donor Profile Index (KDPI) (local) Non-0 ABDR mismatch
Donor Characteristics	Dual Kidney Maximum acceptable Kidney Donor Profile Index (KDPI) (import) Non-0 ABDR mismatch
Donor Characteristics	Minimum acceptable donor age (local)
Donor Characteristics	Minimum acceptable donor age (import)
Donor Characteristics	Maximum acceptable donor age (local)
Donor Characteristics	Maximum acceptable donor age (import)
Donor Characteristics	Maximum acceptable donor BMI
Donor Characteristics	Accept DCD donor? (local)
Donor Characteristics	Accept DCD donor? (import)
Medical and Social History	Accept a donor with a history of diabetes?
Medical and Social History	Accept a donor with a history of hypertension?
Infectious Diseases	Accept a Hepatitis B core antibody positive donor?
Infectious Diseases	Accept an HBV NAT positive donor?
Infectious Diseases	Accept an HCV antibody positive donor?
Infectious Diseases	Accept an HCV NAT positive donor?
Hope Act IRB Research	Is the candidate HIV positive and willing to accept an HIV positive Kidney?
Recovery	Maximum acceptable warm ischemic time
Recovery	Maximum acceptable cold ischemic time
Recovery	Maximum acceptable percent globally sclerotic glomeruli - 10 or more glomeruli observed (local)
Recovery	Maximum acceptable percent globally sclerotic glomeruli- 10 or more glomeruli observed (import)
Recovery	Maximum acceptable percent globally sclerotic glomeruli - Less than 10 glomeruli observed (local)
Recovery	Maximum acceptable percent globally sclerotic glomeruli - Less than 10 glomeruli observed (import)
Lab Values	Maximum acceptable donor serum creatinine - Peak (local)
Lab Values	Maximum acceptable donor serum creatinine - Peak (import)
Lab Values	Maximum acceptable donor serum creatinine - Final (local)
Lab Values	Maximum acceptable donor serum creatinine - Final (import)
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].