| Pediatric Pancreas Candidate Listing Registration |
| Fields to be completed by members |
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| Form Section |
Field Label |
Notes |
| Add new candidate registration |
Center |
Display Only - Cascades from database |
| Add new candidate registration |
Organ |
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| Candidate Add |
Center |
Display Only - Cascades from database |
| Candidate Add |
Organ |
Display Only - Cascades from database |
| Candidate Add |
SSN |
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| Candidate Add |
Confirm SSN |
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| Candidate Add |
Age Group |
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| Provider Information |
Transplant Center |
Display Only - Cascades from database |
| Provider Information |
24 Hour Contact Phone Number |
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| Demographic Information |
SSN |
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| Demographic Information |
Confirm SSN |
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| Demographic Information |
Last Name |
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| Demographic Information |
First Name |
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| Demographic Information |
MI |
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| Demographic Information |
Date of birth |
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| Demographic Information |
Confirm date of birth |
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| Demographic Information |
Birth sex |
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| Demographic Information |
Center Patient ID |
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| Demographic Information |
State of Permanent Residence |
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| Demographic Information |
Permanent ZIP Code |
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| Demographic Information |
Ethnicity |
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| Demographic Information |
Race |
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| Pancreas Islet Organ Information |
Candidate Medical Urgency Status |
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| Pancreas Islet Organ Information |
Inactive reason |
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| Pancreas Islet Organ Information |
Has candidate had a prior Kidney transplant? |
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| Pancreas Islet Organ Information |
Number of previous Pancreas transplants |
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| Clinical Information |
ABO |
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| Clinical Information |
Height (ft) |
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| Clinical Information |
Height (in) |
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| Clinical Information |
Height (cm) |
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| Clinical Information |
Weight (lbs) |
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| Clinical Information |
Weight (kg) |
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| HLA CLASS I |
A |
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| HLA CLASS I |
A |
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| HLA CLASS I |
B |
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| HLA CLASS I |
B |
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| HLA CLASS I |
BW4 |
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| HLA CLASS I |
BW6 |
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| HLA CLASS I |
C |
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| HLA CLASS I |
C |
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| HLA CLASS II |
DR |
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| HLA CLASS II |
DR |
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| HLA CLASS II |
DR51 |
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| HLA CLASS II |
DR51 |
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| HLA CLASS II |
DR52 |
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| HLA CLASS II |
DR52 |
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| HLA CLASS II |
DR53 |
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| HLA CLASS II |
DR53 |
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| HLA CLASS II |
DQB1 |
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| HLA CLASS II |
DQB1 |
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| HLA CLASS II |
DQA1 |
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| HLA CLASS II |
DQA1 |
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| HLA CLASS II |
DPB1 |
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| HLA CLASS II |
DPB1 |
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| HLA CLASS II |
DPA1 |
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| HLA CLASS II |
DPA1 |
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| Confirm HLA CLASS I |
A |
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| Confirm HLA CLASS I |
A |
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| Confirm HLA CLASS I |
B |
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| Confirm HLA CLASS I |
B |
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| Confirm HLA CLASS I |
BW4 |
|
| Confirm HLA CLASS I |
BW6 |
|
| Confirm HLA CLASS I |
C |
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| Confirm HLA CLASS I |
C |
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| Confirm HLA CLASS II |
DR |
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| Confirm HLA CLASS II |
DR |
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| Confirm HLA CLASS II |
DR51 |
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| Confirm HLA CLASS II |
DR51 |
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| Confirm HLA CLASS II |
DR52 |
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| Confirm HLA CLASS II |
DR52 |
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| Confirm HLA CLASS II |
DR53 |
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| Confirm HLA CLASS II |
DR53 |
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| Confirm HLA CLASS II |
DQB1 |
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| Confirm HLA CLASS II |
DQB1 |
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| Confirm HLA CLASS II |
DQA1 |
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| Confirm HLA CLASS II |
DQA1 |
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| Confirm HLA CLASS II |
DPB1 |
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| Confirm HLA CLASS II |
DPB1 |
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| Confirm HLA CLASS II |
DPA1 |
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| Confirm HLA CLASS II |
DPA1 |
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| HLA |
Tested for anti HLA antibodies |
|
| Additional Organs |
Select any additional organs the candidate may need. |
|
| Pancreas Donor Acceptance Criteria |
ABDR |
|
| Pancreas Donor Acceptance Criteria |
AB |
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| Pancreas Donor Acceptance Criteria |
ADR |
|
| Pancreas Donor Acceptance Criteria |
BDR |
|
| Pancreas Donor Acceptance Criteria |
B |
|
| Pancreas Donor Acceptance Criteria |
A |
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| Pancreas Donor Acceptance Criteria |
DR |
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| Pancreas Donor Acceptance Criteria |
Preliminary Crossmatch Required |
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| Pancreas Donor Acceptance Criteria |
Accept pancreas procured by another team? |
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| Donor Characteristics |
Minimum acceptable donor age (Local) |
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| Donor Characteristics |
Minimum acceptable donor age (Import) |
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| Donor Characteristics |
Maximum acceptable donor age (Local) |
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| Donor Characteristics |
Maximum acceptable donor age (Import) |
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| Donor Characteristics |
Minimum acceptable donor weight |
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| Donor Characteristics |
Maximum acceptable donor weight |
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| Donor Characteristics |
Maximum acceptable donor BMI |
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| Donor Characteristics |
Local Accept DCD donor (Local) |
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| Donor Characteristics |
Import Accept DCD donor (Import) |
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| Medical and Social History |
Accept a donor with a history of diabetes? |
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| Infectious diseases |
Accept a Hepatitis B core antibody positive donor? |
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| Infectious diseases |
Accept an HBV NAT positive donor? |
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| Infectious diseases |
Accept an HCV antibody positive donor? |
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| Infectious diseases |
Accept an HCV NAT positive donor? |
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| Recovery |
Maximum acceptable cold ischemic time |
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| Recovery |
Maximum nautical miles the organ or recovery team will travel |
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| Lab values |
Maximum acceptable donor serum amylase - peak |
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| Lab values |
Maximum acceptable donor serum lipase - peak |
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| Unacceptable Antigens |
A |
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| Unacceptable Antigens |
B |
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| Unacceptable Antigens |
BW |
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| Unacceptable Antigens |
C |
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| Unacceptable Antigens |
DR |
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| Unacceptable Antigens |
DR51 |
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| Unacceptable Antigens |
DR52 |
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| Unacceptable Antigens |
DR53 |
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| Unacceptable Antigens |
DQB1 |
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| Unacceptable Antigens |
DQA1 |
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| Unacceptable Antigens |
DPB1 - unacceptable antigens |
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| Unacceptable Antigens |
DPB1 - unacceptable epitopes |
|
| Unacceptable Antigens |
DPA1 |
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| Verify ABO |
ABO |
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| OMB No. 0915-0157; Expiration Date: XX/XX/20XX |
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| PUBLIC BURDEN STATEMENT: |
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| 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]. |