81 Adult Intestine Candidate Listing Registration

Data System for Organ Procurement and Transplantation Network

81. Adult Intestine Candidate Listing Registration_Form.xlsx

Adult Intestine Candidate Listing Registration

OMB: 0915-0157

Document [xlsx]
Download: xlsx | pdf
Adult Intestine Candidate Listing Registration
Fields to be completed by members



Form Section Field Label Notes
Add new candidate registration Transplant Hospital Display only - Cascade from database
Add new candidate registration Organ
Candidate Add Center Display only - Cascade from database
Candidate Add Organ Display only - Cascade from database
Candidate Add Age group
Candidate Add SSN
Candidate Add Confirm SSN
Provider Information Transplant Center Display only - Cascade 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
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
Organ Information Candidate Medical Urgency Status
Organ Information Inactive Reason
Organ Information Preliminary Crossmatch Required
Organ Information Accept intestine if removed by another procurement team?
Organ Information Accept intestine if kidney procured?
Organ Information Accept intestine if pancreas procured?
Organ Information Accept intestine if liver procured?
Organ Information Number of previous Intestine Transplants
Status 1 Justification Form Status Display Only
Status 1 Justification Form Surgeon/Physician NPI
Status 1 Justification Form Surgeon/Physician Name
Status 1 Justification Form Hospital Telephone Number
Status 1 Justification Form Primary Diagnosis
Status 1 Justification Form Specify
Status 1 Justification Form Secondary Diagnosis
Status 1 Justification Form Specify
Status 1 Justification Form The patient no longer has vascular access through the subclavian, jugular or femoral veins for intravenous feeding
Status 1 Justification Form The patient has abnormal liver function test values
Status 1 Justification Form Total Bilirubin - Date
Status 1 Justification Form Total Bilirubin - Value
Status 1 Justification Form Alkaline Phosphatase - Date
Status 1 Justification Form Alkaline Phosphatase - Value
Status 1 Justification Form SGOT/AST - Date
Status 1 Justification Form SGOT/AST - Value
Status 1 Justification Form SGPT/ALT - Date
Status 1 Justification Form SGPT/ALT - Value
Status 1 Justification Form Albumin - Date
Status 1 Justification Form Albumin - Value
Status 1 Justification Form INR - Date
Status 1 Justification Form INR - Value
Status 1 Justification Form Other
Status 1 Justification Form Justification Narrative
Additional Organs Check any additional organs the candidate may need
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 gastrointestinal disease?
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?
Infectious diseases Accept a CMV antibody positive donor?
Recovery Maximum nautical miles the organ or recovery team will travel
Lab Values Maximum acceptable donor serum creatinine - peak
Lab Values Maximum acceptable donor serum creatinine - final
Lab Values Maximum acceptable donor SGOT (AST) - peak
Lab Values Maximum acceptable donor SGPT (AST) - peak
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].
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