86 Pediatric HeartLung Candidate Listing Registration

Data System for Organ Procurement and Transplantation Network

86. Pediatric HeartLung Candidate Listing Registration_Form.xlsx

Pediatric HeartLung Candidate Listing Registration

OMB: 0915-0157

Document [xlsx]
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Pediatric HeartLung 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 SSN
Candidate Add Confirm SSN
Candidate Add Age Group
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 Accept an Intended Blood Group Incompatible Organ? For pediatric candidates less than 2yrs at time of registration
Clinical Information Height (ft)
Clinical Information Height (in)
Clinical Information Height (cm)
Clinical Information Date
Clinical Information Weight (lbs)
Clinical Information Weight (kg)
Clinical Information Date
Clinical Information BMI Display Only - Calculated
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 Lung Diagnosis Code
Organ Information Indicate reason for change in diagnosis
Organ Information Other specify
Organ Information Functional Status
Organ Information Eval Date
Organ Information Diabetes
Organ Information Eval Date
Organ Information Assisted Ventilation
Organ Information Eval Date
Organ Information Requires Supplemental O2
Organ Information Eval Date
Organ Information Amount
Organ Information Percent
Organ Information Pulmonary Function Test Date
Organ Information Actual Forced Vital Capacity (FVC)
Organ Information Percent Predicted FVC
Organ Information Pre Bronchodilator Actual FEV1
Organ Information Pre Bronchodilator Percent Predicted FEV1
Organ Information Post Bronchodilator Actual FEV1
Organ Information Post Bronchodilator Percent Predicted FEV1
Organ Information Six Minute Walk Distance
Organ Information Test Date
Organ Information Most Recent Heart Catheterization Date
Organ Information Pulmonary Artery Systolic Pressure
Organ Information Pulmonary Artery Diastolic Pressure
Organ Information Mean Pulmonary Artery Pressure
Organ Information Pulmonary Capillary Wedge Mean
Organ Information Cardiac Output (CO)
Organ Information Cardiac Index (CI)
Organ Information Central Venous Pressure (CVP)
Organ Information Test Date
Organ Information Hgb/Hct Test Date
Organ Information Hemoglobin (Hgb)
Organ Information Hematocrit (Hct)
Organ Information Preliminary Crossmatch Required
Organ Information Number of previous Heart/Lung Transplants
Organ Information - Blood Gas Information Date
Organ Information - Blood Gas Information Time
Organ Information - Blood Gas Information Test Type
Organ Information - Blood Gas Information pH
Organ Information - Blood Gas Information PCO2
Organ Information - Blood Gas Information PO2
Organ Information - Blood Gas Information Supplemental O2 at time of test?
Organ Information - Blood Gas Information O2 Amount
Organ Information - Serum Creatinine Date
Organ Information - Serum Creatinine Time
Organ Information - Serum Creatinine Serum Creatinine
Organ Information - Total Bilirubin Date
Organ Information - Total Bilirubin Time
Organ Information - Total Bilirubin Total Bilirubin
Justification Form Status 1A By criteria
Justification Form Status 1A Congenital Heart Disease Diagnosis (Check all that apply)
Justification Form Status 1A Other
Justification Form Status 1A Dobutamine
Justification Form Status 1A Dopamine
Justification Form Status 1A Milrinone
Justification Form Status 1A Epinephrine
Justification Form Status 1A Norepinephrine (Levophed)
Justification Form Status 1A IV Nitroglycerin
Justification Form Status 1A Nesiritide (Natrecor)
Justification Form Status 1A Nitroprusside (Nipride, Nitropress)
Justification Form Status 1A Phenylephrine (Neo-Synephrine)
Justification Form Status 1A Vasopressin (Pitressin)
Justification Form Status 1A By exception
Justification Form Status 1A Justification narrative
Justification Form Status 1A Transplant physician name
Justification Form Status 1A Transplant physician NPI
Justification Form Status 1A Email decision to
Justification Form Status 1B By criteria
Justification Form Status 1B Is less than one year old at the time of the candidate's initial registration and has a diagnosis of hypertrophic or restrictive cardiomyopathy
Justification Form Status 1B By exception
Justification Form Status 1B Justification narrative
Justification Form Status 1B Transplant physician name
Justification Form Status 1B Transplant physician NPI
Justification Form Status 1B Email decision to
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 height Local
Donor Characteristics Minimum acceptable donor height Import
Donor Characteristics Maximum acceptable donor height Local
Donor Characteristics Maximum acceptable donor height Import
Donor Characteristics Minimum acceptable donor weight Local
Donor Characteristics Minimum acceptable donor weight Import
Donor Characteristics Maximum acceptable donor weight Local
Donor Characteristics Maximum acceptable donor weight Import
Donor Characteristics Donor Birth Sex requirements
Donor Characteristics Accept DCD donor? Local
Donor Characteristics Accept DCD donor? Import
Medical and Social History Accept a donor with a history of coronary artery disease?
Medical and Social History Accept a donor with cigarette use > 20 packs years ever?
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
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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