Form 78 Pediatric Pancreas Islet Listing Registration

Pediatric Pancreas Islet Listing Registration
Fields to be completed by members
Form Section	Field Label	Notes
Add new candidate registration	Center	Display Only - Cascades from database
Add new candidate registration	Organ
Candidate Add	Center	Display Only - Cascades from database
Candidate Add	Organ	Display Only - Cascades from database
Add Candidate	SSN
Add Candidate	Confirm SSN
Add Candidate	Age Group
Provider Information	Transplant Hospital	Display only - cascades from database
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
Pancreas Islets Organ Information	Candidate Medical Urgency Status
Pancreas Islets Organ Information	Inactive Reason
Pancreas Islets Organ Information	Number of previous Pancreas Islets Transplants
Clinical Information	ABO
Clinical Information	Height (ft)
Clinical Information	Height (in)
Clinical Information	Height (cm)
Clinical Information	Weight (lbs)
Clinical Information	Weight (kg)
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
Additional Organs	Check any addition organs the candidate may need
Pancreas Islets Donor Acceptance Criteria	ABDR
Pancreas Islets Donor Acceptance Criteria	AB
Pancreas Islets Donor Acceptance Criteria	ADR
Pancreas Islets Donor Acceptance Criteria	BDR
Pancreas Islets Donor Acceptance Criteria	A
Pancreas Islets Donor Acceptance Criteria	B
Pancreas Islets Donor Acceptance Criteria	DR
Pancreas Islets Donor Acceptance Criteria	Preliminary Crossmatch Required
Pancreas Islets Donor Acceptance Criteria	Accept pancreas procured by another team?
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?
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?
Recovery	Maximum nautical miles the organ or recovery team will travel
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 - Antigens
Unacceptable Antigens	DPB1 - Epitopes
Unacceptable Antigens	DPA1
Verify ABO	ABO
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].