73 Adult Kidney Pancreas Candidate Listing Registration

Adult Kidney Pancreas Candidate Listing Registration
Fields to be completed by members
Form Section	Field Label	Notes
Match List	Choose any additional matches that the candidate should appear on
Provider Information	Transplant Hospital	Display Only
Provider Information	24 Hour Contact Phone Number
Demographic Information	SSN
Demographic Information	Confirm SSN
Demographic Information	Last Name
Demographic Information	First Name
Demographic Information	MI
Demographic Information	Date of birth
Demographic Information	Confirm date of birth
Demographic Information	Birth sex
Demographic Information	Center Patient ID
Demographic Information	State of Permanent Residence
Demographic Information	Permanent ZIP Code
Demographic Information	Ethnicity
Demographic Information	Race
Organ Information	Candidate Medical Urgency Status
Organ Information	Inactive reason
Organ Information	Number of previous Kidney transplants
Organ Information	Number of previous Pancreas transplants
Clinical Information	ABO
Clinical Information	Height (ft)
Clinical Information	Height (in)
Clinical Information	Height (cm)
Clinical Information	Date
Clinical Information	Weight (lbs)
Clinical Information	Weight (kg)
Clinical Information	Date
Clinical Information	BMI	Display Only - Calculated
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?
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	C-peptide Value
Clinical Information	C-peptide Date
Clinical Information	Is candidate currently on insulin?
Clinical Information	If on insulin, enter the insulin date
Additional Organs	Check any additional organs the candidate may need.
Kidney/Pancreas Donor Acceptance Criteria	ABDR
Kidney/Pancreas Donor Acceptance Criteria	AB
Kidney/Pancreas Donor Acceptance Criteria	ADR
Kidney/Pancreas Donor Acceptance Criteria	BDR
Kidney/Pancreas Donor Acceptance Criteria	A
Kidney/Pancreas Donor Acceptance Criteria	B
Kidney/Pancreas Donor Acceptance Criteria	DR
Kidney/Pancreas Donor Acceptance Criteria	Preliminary Crossmatch Required
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	Minimum acceptable donor weight
Donor Characteristics	Maximum acceptable donor weight
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-Pancreas?
Recovery	Maximum acceptable cold ischemic time
Recovery	Maximum nautical miles the organ or recovery team will travel
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
Lab values	Maximum acceptable donor serum amylase - peak
Lab values	Maximum acceptable donor serum lipase - peak
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
Isolated Kidney Match Information	Candidate Medical Urgency Status
Isolated Kidney Match Information	Inactive reason
Isolated Kidney Match Information	Number of previous solid organ transplants from OPTN database	Display Only - Cascades from database
Isolated Kidney Match Information	Number of previous solid organ transplants
Isolated Kidney Match Information	Current diabetes status
Medical Urgency Information	Vascular access in the upper left extremity
Medical Urgency Information	Vascular access in the upper right extremity
Medical Urgency Information	Vascular access in the lower left extremity
Medical Urgency Information	Vascular access in the lower right extremity
Medical Urgency Information	Peritoneal access in the abdomen
Medical Urgency Information	Transhepatic IVC catheter
Medical Urgency Information	Translumbar IVC catheter
Medical Urgency Information	Other (must specify)
Medical Urgency Information	Other (must specify) (Text Field)
Medical Urgency Information	Nephrologist full name
Medical Urgency Information	Nephrologist NPI
Medical Urgency Information	Surgeon full name
Medical Urgency Information	Surgeon NPI
A2/A2B Eligibility	Does candidate meet criteria for A2/A2B (including patient consent)?
Kidney Donor Acceptance Criteria	ABDR
Kidney Donor Acceptance Criteria	AB
Kidney Donor Acceptance Criteria	ADR
Kidney Donor Acceptance Criteria	BDR
Kidney Donor Acceptance Criteria	A
Kidney Donor Acceptance Criteria	B
Kidney Donor Acceptance Criteria	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)_x000D_ 0 ABDR mismatch - Single Kidney	Local
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI)_x000D_ 0 ABDR mismatch - Single Kidney	Import
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI)_x000D_ Non-0 ABDR mismatch - Single Kidney	Local
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI)_x000D_ Non-0 ABDR mismatch - Single Kidney	Import
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI)_x000D_ 0 ABDR mismatch - Dual Kidney	Local
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI)_x000D_ 0 ABDR mismatch - Dual Kidney	Import
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI)_x000D_ Non-0 ABDR mismatch - Dual Kidney	Local
Donor Characteristics	Maximum acceptable Kidney Donor Profile Index (KDPI)_x000D_ Non-0 ABDR mismatch - Dual Kidney	Import
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 with less than 10 glomeruli observed	Local
Recovery	Maximum acceptable percent globally sclerotic glomeruli with less than 10 glomeruli observed	Import
Recovery	Maximum acceptable percent globally sclerotic glomeruli with 10 or more glomeruli observed	Local
Recovery	Maximum acceptable percent globally sclerotic glomeruli with 10 or more 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
Isolated Pancreas Match Information	Candidate Medical Urgency Status
Isolated Pancreas Match Information	Inactive reason
Isolated Pancreas Match Information	ABDR
Isolated Pancreas Match Information	AB
Isolated Pancreas Match Information	ADR
Isolated Pancreas Match Information	BDR
Isolated Pancreas Match Information	A
Isolated Pancreas Match Information	B
Isolated Pancreas Match Information	DR
Isolated Pancreas Match Information	Preliminary Crossmatch Required
Isolated Pancreas Match Information	Accept Pancreas procured by another team?
Isolated Pancreas Match Information	Maximum nautical miles the organ or recovery team will travel?
Verify ABO	ABO
HIV Verification	Is the candidate HIV positive and willing to accept an HIV positive Kidney-Pancreas?
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].