83 Adult Heart Candidate Listing Registration

Data System for Organ Procurement and Transplantation Network

83. Adult Heart Candidate Listing Registration_Form.xlsx

Adult Heart Candidate Listing Registration

OMB: 0915-0157

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Adult Heart 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's Patient ID
Demographic Information State of Permanent Residence
Demographic Information Permanent ZIP Code
Demographic Information Ethnicity
Demographic Information Race
Clinical Information ABO
Clinical Information Accept an Intended Blood Group Incompatible Organ?
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 Heart Diagnosis Code
Organ Information Preliminary Crossmatch Required
Organ Information Number of previous Heart Transplants
Organ Information Is the candidate listed for a vascularized composite allograft (VCA)?
Additional Organs Check any additional organs the candidate may need.
Donor Characteristics Local Minimum acceptable donor age
Donor Characteristics Import Minimum acceptable donor age
Donor Characteristics Local Maximum acceptable donor age
Donor Characteristics Import Maximum acceptable donor age
Donor Characteristics Local Minimum acceptable donor height
Donor Characteristics Import Minimum acceptable donor height
Donor Characteristics Local Maximum acceptable donor height
Donor Characteristics Import Maximum acceptable donor height
Donor Characteristics Local Minimum acceptable donor weight
Donor Characteristics Import Minimum acceptable donor weight
Donor Characteristics Local Maximum acceptable donor weight
Donor Characteristics Import Maximum acceptable donor weight
Donor Characteristics Donor birth sex requirements
Donor Characteristics Local Accept DCD donor?
Donor Characteristics Import Accept DCD donor?
Medical and Social History Accept a donor with a history of coronary artery disease?
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
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
Risk Stratification Data Total number of prior sternotomies
Risk Stratification Data Any prior history of stroke?
Risk Stratification Data Any prior history of peripheral thromboembolic events?
Risk Stratification Data Number of hospitalizations for heart failure in last 12 months
Risk Stratification Data Is the candidate on a diuretic?
Risk Stratification Data Furosemide - Amount
Risk Stratification Data Furosemide - IV/PO
Risk Stratification Data Torsemide - Amount
Risk Stratification Data Torsemide - IV/PO
Risk Stratification Data Bumetanide - Amount
Risk Stratification Data Bumetanide - IV/PO
Risk Stratification Data Chlorothiazide - Amount
Risk Stratification Data Chlorothiazide - IV/PO
Risk Stratification Data Metolazone - Amount
Risk Stratification Data Metolazone - IV/PO
Risk Stratification Data Other diuretic - Name
Risk Stratification Data Other diuretic - Amount
Risk Stratification Data Other diuretic - IV/PO
Risk Stratification Data Is the candidate on vasoactive support?
Risk Stratification Data Dobutamine
Risk Stratification Data Dopamine
Risk Stratification Data Milrinone
Risk Stratification Data Epinephrine
Risk Stratification Data Norepinephrine
Risk Stratification Data Vasopressin
Risk Stratification Data Is the candidate on anti-arrhythmics?
Risk Stratification Data Is the candidate on pulmonary vasodilators?
Risk Stratification Data Pulmonary Vasodilators Specify
Risk Stratification Data Is the candidate on dialysis?
Risk Stratification Data Is the candidate on continuous invasive mechanical ventilation?
Risk Stratification Data Most Recent Cardiopulmonary Stress Test
Risk Stratification Data Peak O2 consumption
Risk Stratification Data Respiratory exchange ratio (RER)
Risk Stratification Data VE/VCO2
Risk Stratification Data Most Recent Sensitization Data
Risk Stratification Data CPRA
Risk Stratification Data PRA typing method
Risk Stratification Data Other Specify
Risk Stratification Data MFI threshold
Risk Stratification Data Most Recent Hemodynamic Data
Risk Stratification Data Hemodynamic data obtained using
Risk Stratification Data Other Specify
Risk Stratification Data Hemodynamic values were obtained when candidate was on
Risk Stratification Data Systolic blood pressure
Risk Stratification Data Diastolic blood pressure
Risk Stratification Data Resting heart rate (on same date as hemodynamic test)
Risk Stratification Data Central venous pressure
Risk Stratification Data Pulmonary artery systolic pressure
Risk Stratification Data Pulmonary artery diastolic pressure
Risk Stratification Data Mean pulmonary arty pressure
Risk Stratification Data Value obtained for PCWP or LVEDP
Risk Stratification Data PCWP/LVEDP - Amount
Risk Stratification Data Cardiac output
Risk Stratification Data Cardiac index
Risk Stratification Data Mixed venous oxygen saturation (SvO2)
Risk Stratification Data Hemoglobin at time of SvO2
Risk Stratification Data Most Recent Data for VAD patients
Risk Stratification Data LDH
Risk Stratification Data Test date
Risk Stratification Data Plasma free hemoglobin
Risk Stratification Data Test date
Risk Stratification Data Has the candidate experience hemoglobinuria?
Risk Stratification Data Most Recent Heart Failure Severity Data
Risk Stratification Data Serum sodium
Risk Stratification Data Test date
Risk Stratification Data Serum creatinine
Risk Stratification Data Test date
Risk Stratification Data BUN
Risk Stratification Data Test date
Risk Stratification Data Serum albumin
Risk Stratification Data Test date
Risk Stratification Data AST
Risk Stratification Data Test date
Risk Stratification Data Serum bilirubin
Risk Stratification Data Test date
Risk Stratification Data Arterial lactate
Risk Stratification Data Test date
Risk Stratification Data INR
Risk Stratification Data Test date
Risk Stratification Data Brain natriuretic peptide test performed
Risk Stratification Data BNP test type
Risk Stratification Data BNP/NT Pro BNP - Amount
Risk Stratification Data Test date
Justification Form Information Surgeon/Physician NPI
Justification Form Information Surgeon/Physician name
Justification Form Information Hospital Telephone Number
Justification Form Status 1 Is the candidate currently admitted to the listing transplant hospital?
Justification Form Status 1 Primary device
Justification Form Status 1 Non-Dischargeable VAD Device Brand
Justification Form Status 1 Other specify
Justification Form Status 1 Dischargeable VAD Device Brand
Justification Form Status 1 Other specify
Justification Form Status 1 Date of implant/initiation
Justification Form Status 1 Time of implant/initiation
Justification Form Status 1 Ventricle support
Justification Form Status 1 Secondary device
Justification Form Status 1 Device Brand
Justification Form Status 1 Other specify
Justification Form Status 1 Date of implant/initiation
Justification Form Status 1 Ventricle support
Justification Form Status 1 Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO)
Justification Form Status 1 Select one of the following
Justification Form Status 1 Was the candidate on inotropes at the time cardiac index was obtained?
Justification Form Status 1 Cardiac index
Justification Form Status 1 Test Date
Justification Form Status 1 Test Time
Justification Form Status 1 Pulmonary capillary wedge pressure
Justification Form Status 1 Test Date
Justification Form Status 1 Test Time
Justification Form Status 1 Systolic blood pressure
Justification Form Status 1 Test Date
Justification Form Status 1 Test Time
Justification Form Status 1 Date of administration of CPR
Justification Form Status 1 Test Time
Justification Form Status 1 Systolic blood pressure
Justification Form Status 1 Test Date
Justification Form Status 1 Test Time
Justification Form Status 1 Arterial lactate
Justification Form Status 1 Test Date
Justification Form Status 1 Test Time
Justification Form Status 1 Aspartate transaminase
Justification Form Status 1 Test Date
Justification Form Status 1 Test Time
Justification Form Status 1 Alanine transaminase
Justification Form Status 1 Test Date
Justification Form Status 1 Test Time
Justification Form Status 1 Non-dischargeable, surgically implanted, non-endovascular biventricular support device
Justification Form Status 1 Mechanical circulatory support device (MCSD) with life threatening ventricular arrhythmia
Justification Form Status 1 Select at least one of the following
Justification Form Status 1 Exception for status 1
Justification Form Status 1 This exception request is specifically related to a device recall
Justification Form Status 2 Clinical Narrative
Justification Form Status 2 Primary device
Justification Form Status 2 Non-Dischargeable VAD Device Brand
Justification Form Status 2 Other specify
Justification Form Status 2 Dischargeable VAD Device Brand
Justification Form Status 2 Other specify
Justification Form Status 2 Date of implant/initiation
Justification Form Status 2 Time of implant/initiation
Justification Form Status 2 Ventricle support
Justification Form Status 2 Secondary device
Justification Form Status 2 Device Brand
Justification Form Status 2 Other specify
Justification Form Status 2 Date of implant/initiation
Justification Form Status 2 Ventricle support
Justification Form Status 2 Non-dischargeable, surgically implanted, non-endovascular left ventricular assist device (LVAD)
Justification Form Status 2 Total artificial heart (TAH), BiVAD, right ventricular assist device (RVAD), or ventricular assist device (VAD) for single ventricle patients
Justification Form Status 2 Mechanical circulatory support device (MCSD) with malfunction
Justification Form Status 2 Percutaneous endovascular mechanical circulatory support device
Justification Form Status 2 Hemodynamic measurements were obtained and within 24 hour period
Justification Form Status 2 Cardiac index
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Pulmonary capillary wedge pressure
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Systolic blood pressure
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Hemodynamic measurements were not obtained. However, within 24 hours prior to IABP support
Justification Form Status 2 Date of administration of CPR
Justification Form Status 2 Test Time
Justification Form Status 2 Systolic blood pressure
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Arterial lactate
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Aspartate transaminase
Justification Form Status 2 Test Time
Justification Form Status 2 Test Date
Justification Form Status 2 Alanine transaminase
Justification Form Status 2 Test Time
Justification Form Status 2 Test Date
Justification Form Status 2 Intra-aortic balloon pump
Justification Form Status 2 Hemodynamic measurements were obtained and within 24 hour period
Justification Form Status 2 Was the candidate on inotropes at the time cardiac index was obtained?
Justification Form Status 2 Cardiac index
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Pulmonary capillary wedge pressure
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Systolic blood pressure
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Hemodynamic measurements were not obtained. However, within 24 hours prior to IABP support
Justification Form Status 2 Date of administration of CPR
Justification Form Status 2 Test Time
Justification Form Status 2 Systolic blood pressure
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Arterial lactate
Justification Form Status 2 Test Date
Justification Form Status 2 Test Time
Justification Form Status 2 Aspartate transaminase
Justification Form Status 2 Test Time
Justification Form Status 2 Test Date
Justification Form Status 2 Alanine transaminase
Justification Form Status 2 Test Time
Justification Form Status 2 Test Date
Justification Form Status 2 Ventricular tachycardia (VT) or ventricular fibrillation (VF)
Justification Form Status 2 Exception for status 2
Justification Form Status 2 This exception request is specifically related to a device recall
Justification Form Status 2 Clinical Narrative
Justification Form Status 3 Primary device
Justification Form Status 3 Non-Dischargeable VAD Device Brand
Justification Form Status 3 Other specify
Justification Form Status 3 Dischargeable VAD Device Brand
Justification Form Status 3 Other specify
Justification Form Status 3 Date of implant/initiation
Justification Form Status 3 Time of implant/initiation
Justification Form Status 3 Ventricle support
Justification Form Status 3 Secondary device
Justification Form Status 3 Device Brand
Justification Form Status 3 Other specify
Justification Form Status 3 Date of implant/initiation
Justification Form Status 3 Ventricle support
Justification Form Status 3 Dischargeable left ventricular assist device (LVAD) for discretionary 30 days
Justification Form Status 3 Multiple inotropes or a single high dose inotrope and hemodynamic monitoring
Justification Form Status 3 Select one of the following
Justification Form Status 3 Candidate is supported by either
Justification Form Status 3 Was the candidate on inotropic or mechanical support at the time cardiac index was obtained?
Justification Form Status 3 Cardiac index
Justification Form Status 3 Test Date
Justification Form Status 3 Test Time
Justification Form Status 3 Pulmonary capillary wedge pressure
Justification Form Status 3 Test Date
Justification Form Status 3 Test Time
Justification Form Status 3 Systolic blood pressure
Justification Form Status 3 Test Date
Justification Form Status 3 Test Time
Justification Form Status 3 Mechanical circulatory support device (MCSD) with hemolysis
Justification Form Status 3 Two separate samples collected within 48 hours of each other confirming markers of active hemolysis as evidenced by at least two of the following
Justification Form Status 3 Mechanical circulatory support device (MCSD) with pump thrombosis
Justification Form Status 3 Mechanical circulatory support device (MCSD) with right heart failure
Justification Form Status 3 Dobutamine
Justification Form Status 3 Date of Initiation
Justification Form Status 3 Dopamine
Justification Form Status 3 Date of Initiation
Justification Form Status 3 Epinephrine
Justification Form Status 3 Date of Initiation
Justification Form Status 3 Milrinone
Justification Form Status 3 Date of Initiation
Justification Form Status 3 Inhaled nitric oxide
Justification Form Status 3 Date of Initiation
Justification Form Status 3 Intravenous prostacyclin
Justification Form Status 3 Date of Initiation
Justification Form Status 3 Pulmonary capillary wedge pressure
Justification Form Status 3 Test Date
Justification Form Status 3 Test Time
Justification Form Status 3 Central venous pressure
Justification Form Status 3 Test Date
Justification Form Status 3 Test Time
Justification Form Status 3 Mechanical circulatory support device (MCSD) with device infection
Justification Form Status 3 Mechanical circulatory support device (MCSD) with mucosal bleeding
Justification Form Status 3 Number of hospitalizations for mucosal bleeding within the past six months
Justification Form Status 3 Mechanical circulatory support device (MCSD) with aortic insufficiency (AI)
Justification Form Status 3 Veno-arterial extracorporeal membrane oxygenation (VA ECMO) after 7 days
Justification Form Status 3 Non-dischargeable, surgically implanted, non-endovascular left ventricular assist device (LVAD) after 14 days
Justification Form Status 3 Percutaneous endovascular circulatory support device after 14 days
Justification Form Status 3 Intra-aortic balloon pump after 14 days
Justification Form Status 3 Exception for status 3
Justification Form Status 3 This exception request is specifically related to a device recall
Justification Form Status 3 Clinical Narrative
Justification Form Status 4 Primary device
Justification Form Status 4 Non-Dischargeable VAD Device Brand
Justification Form Status 4 Other specify
Justification Form Status 4 Dischargeable VAD Device Brand
Justification Form Status 4 Other specify
Justification Form Status 4 Date of implant/initiation
Justification Form Status 4 Time of implant/initiation
Justification Form Status 4 Ventricle support
Justification Form Status 4 Secondary device
Justification Form Status 4 Device Brand
Justification Form Status 4 Other specify
Justification Form Status 4 Date of implant/initiation
Justification Form Status 4 Ventricle support
Justification Form Status 4 Dischargeable left ventricular assist device (LVAD) without discretionary 30 days
Justification Form Status 4 Inotropes without hemodynamic monitoring
Justification Form Status 4 Dobutamine
Justification Form Status 4 Date of Initiation
Justification Form Status 4 Milrinone
Justification Form Status 4 Date of Initiation
Justification Form Status 4 Epinephrine
Justification Form Status 4 Date of Initiation
Justification Form Status 4 Dopamine
Justification Form Status 4 Date of Initiation
Justification Form Status 4 Cardiac index
Justification Form Status 4 Test Date
Justification Form Status 4 Pulmonary capillary wedge pressure
Justification Form Status 4 Test Date
Justification Form Status 4 Congenital heart disease
Justification Form Status 4 Congenital Heart Disease Diagnosis
Justification Form Status 4 Other
Justification Form Status 4 Ischemic heart disease with intractable angina
Justification Form Status 4 Amyloidosis, or hypertrophic or restrictive cardiomyopathy
Justification Form Status 4 Candidate is diagnosed with at least one of the following
Justification Form Status 4 Candidate meets at least one of the following requirements
Justification Form Status 4 New York Heart Association (NYHA) Class III-IV symptoms with either
Justification Form Status 4 Retransplant
Justification Form Status 4 Exception for status 4
Justification Form Status 4 Clinical Narrative
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