Document
Pediatric Pancreas Islet Listing Registration
ICR 202506-0915-004 · OMB 0915-0157 · Object 159333501.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | Pediatric Pancreas Islet Listing Registration |
| Author | Michael Hollister |
| Last Modified By | Calc |
| File Modified | 2024-11-20 |
| File Created | 2026-09-13 |
| Conversion State | complete |
Extracted Text
Pediatric Pancreas Islet Listing Registration Fields to be completed by members Form Section Add new candidate registration Add new candidate registration Candidate Add Candidate Add Add Candidate Add Candidate Add Candidate Provider Information Provider Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Demographic Information Pancreas Islets Organ Information Pancreas Islets Organ Information Pancreas Islets Organ Information Field Label Center Organ Center Organ SSN Confirm SSN Age Group Transplant Hospital 24 Hour Contact Phone Number SSN Confirm SSN Last Name First Name MI Date of birth Confirm date of birth Birth sex Center Patient ID State of Permanent Residence Permanent ZIP Code Ethnicity Race Candidate Medical Urgency Status Inactive Reason Number of previous Pancreas Islets Transplants ABO Height (ft) Height (in) Height (cm) Weight (lbs) Weight (kg) A A B B BW4 BW6 C C Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information Clinical Information HLA CLASS I HLA CLASS I HLA CLASS I HLA CLASS I HLA CLASS I HLA CLASS I HLA CLASS I HLA CLASS I _x000D_ OPTN Restricted # HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II HLA CLASS II Confirm HLA CLASS I Confirm HLA CLASS I Confirm HLA CLASS I Confirm HLA CLASS I Confirm HLA CLASS I Confirm HLA CLASS I Confirm HLA CLASS I Confirm HLA CLASS I Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Confirm HLA CLASS II Additional Organs Pancreas Islets Donor Acceptance Criteria Pancreas Islets Donor Acceptance Criteria Pancreas Islets Donor Acceptance Criteria DR DR DR51 DR51 DR52 DR52 DR53 DR53 DQB1 DQB1 DQA1 DQA1 DPB1 DPB1 DPA1 DPA1 A A B B BW4 BW6 C C DR DR DR51 DR51 DR52 DR52 DR53 DR53 DQB1 DQB1 DQA1 DQA1 DPB1 DPB1 DPA1 DPA1 Check any addition organs the candidate may need ABDR AB ADR _x000D_ OPTN Restricted # Pancreas Islets Donor Acceptance Criteria Pancreas Islets Donor Acceptance Criteria Pancreas Islets Donor Acceptance Criteria Pancreas Islets Donor Acceptance Criteria Pancreas Islets Donor Acceptance Criteria Pancreas Islets Donor Acceptance Criteria Donor Characteristics Donor Characteristics Donor Characteristics Donor Characteristics Donor Characteristics Donor Characteristics Donor Characteristics Donor Characteristics Donor Characteristics Medical and Social History Infectious Diseases Infectious Diseases Infectious Diseases Infectious Diseases Recovery Lab Values Lab Values Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Unacceptable Antigens Verify ABO BDR A B DR Preliminary Crossmatch Required Accept pancreas procured by another team? Minimum acceptable donor age (Local) Minimum acceptable donor age (Import) Maximum acceptable donor age (Local) Maximum acceptable donor age (Import) Minimum acceptable donor weight Maximum acceptable donor weight Maximum acceptable donor BMI Accept DCD donor (Local) Accept DCD donor (Import) Accept a donor with a history of diabetes? Accept a Hepatitis B core antibody positive donor? Accept an HBV NAT positive donor? Accept an HCV antibody positive donor? Accept an HCV NAT positive donor? Maximum nautical miles the organ or recovery team will travel Maximum acceptable donor serum amylase peak Maximum acceptable donor serum lipase peak A B BW C DR DR51 DR52 DR53 DQB1 DQA1 DPB1 - Antigens DPB1 - Epitopes DPA1 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 t functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monit organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respo OPTN Restricted unless it displays a currently valid _x000D_ OMB control number. The OMB control number for this information collection is XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data c # The private, non-profit Organ Procurement and Transplantation Network (OPTN) collects this information in order t functions: to assess whether applicants meet OPTN Bylaw requirements for membership in the OPTN; and to monit organizations with OPTN Obligations. An agency may not conduct or sponsor, and a person is not required to respo unless it displays a currently valid OMB control number. The OMB control number for this information collection is XX/XX/202X. This information collection is required to obtain or retain a benefit per 42 CFR §121.11(b)(2). All data c Act protection (Privacy Act System of Records #09-15-0055). Data collected by the private non-profit OPTN also are Contractor’s security features. The Contractor’s security system meets or exceeds the requirements as prescribed b Security of Federal Automated Information Systems, and the Departments Automated Information Systems Securit reporting burden for this collection of information is estimated to average 0.27 hours per response, including the ti searching existing data sources, and completing and reviewing the collection of information. Send comments regar other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information C Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. _x000D_ OPTN Restricted # egistration mbers Notes Display Only - Cascades from database Display Only - Cascades from database Display Only - Cascades from database Display only - cascades from database _x000D_ OPTN Restricted # _x000D_ OPTN Restricted # this information in order to perform the following OPTN n the OPTN; and to monitor compliance of member n is not required to respond to, a collection of information information collection is 0915-0157 and it is valid until _x000D_ OPTN Restricted R §121.11(b)(2). All data collected will be subject to Privacy # this information in order to perform the following OPTN n the OPTN; and to monitor compliance of member n is not required to respond to, a collection of information information collection is 0915-0157 and it is valid until R §121.11(b)(2). All data collected will be subject to Privacy non-profit OPTN also are well protected by a number of the uirements as prescribed by OMB Circular A-130, Appendix III, ormation Systems Security Program Handbook. The public response, including the time for reviewing instructions, on. Send comments regarding this burden estimate or any en, to HRSA Information Collection Clearance Officer, 5600 _x000D_ OPTN Restricted #