VCA Musculoskeletal Composite Graft Segment Candidate Listing Registration

OMB No. 0915-0157; Expiration Date: XX/XX/20XX

VCA Musculoskeletal Composite Graft Segment Candidate Registration

The fields on the VCA - Musculoskeletal Composite Graft Segment Candidate Registration form contain demographic and basic clinical information about candidates on the national waiting list.

Provider

Transplant Hospital: Verify the transplant hospital name, and that the provider number is the 6-character Medicare identification number of the hospital where the transplant candidate is listed.

24 Hour Contact Phone Number: Verify the transplant center phone number. This is a required field.

Waitlist Registration

Organ Registration: Verify organ type.

Candidate Identification

SSN: Enter the candidate’s social security number.

Note: SSN cannot:

Contain 00 in the 4th and 5th place (e.g., XXX-00-XXXX is invalid)

Contain 0000 in the last 4 places (e.g., XXX-XX-0000 is invalid)

Begin with 666

Confirm SSN: Re-enter candidate SSN. A green check mark indicates that the data matches.

Date of birth: Enter the candidate's date of birth. This is a required field.

Confirm date of birth: Re-enter candidate date of birth. A green check mark indicates that the data matches.

Center patient ID: Enter the candidate's patient identification number that is assigned by your center, if applicable.

Demographics

Last Name: Enter the last name of the candidate. This is a required field.

First Name: Enter the first name of the candidate. This is a required field.

MI: Enter the candidate's middle initial.

Birth sex: Indicate if the patient is Male or Female. Report patient sex (male or female), based on biologic and physiologic traits at birth. This is a required field.

State of Permanent Residence: Select the full name of the state where the candidate's home is located.

Permanent Zip Code: Enter the 5-digit or 9-digit U.S. postal zip code for the address where the candidate's home is located.

Ethnicity: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of ethnicity is aligned to this standard.

OMB defines ethnicity to be whether a person self-identifies as Hispanic origin or not. For this reason, ethnicity is broken out in two categories, (1) Hispanic or Latino or (2) Not Hispanic or Latino. Select one ethnicity category or select ‘Ethnicity Not Reported’ if the candidate did not self-identify. This field is required.

Hispanic or Latino – A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Not Hispanic or Latino

Ethnicity Not Reported

Race: The Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity (Office of Management and Budget (OMB) Statistical Policy Directive No. 15) define the minimum standards for collecting and presenting data on race and ethnicity for all Federal reporting. The OPTN collection of race is aligned to this standard. OMB defines race as a person’s self-identification with one or more social groups. ​

An individual can select one or more race categories (1) White, (2) Black or African American, (3) Asian, (4) American Indian or Alaska Native, (5) Native Hawaiian or Other Pacific Islander. Select 'Race Not Reported' if the candidate’s race is not reported.​ This field is required.​

Note: A person may report multiple races. Persons reporting Hispanic or Latino ethnicity may report themselves as any race category or report no race at all.

Select one or more race sub-categories or origins. Select 'Other Origin' if origin is not listed. Select 'Origin Not Reported' if the origin was not self-identified by the person.​​

White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.​

European Descent​

Arab or Middle Eastern​

North African (non-Black)​

Other Origin​

Origin Not Reported​​

Black or African American – A person having origins in any of the Black racial groups of Africa. ​

African American ​

African (Continental)​

West Indian​

Haitian​

Other Origin​

Origin Not Reported ​​

American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.​

American Indian​

Eskimo​

Aleutian​

Alaska Indian ​

Other Origin​

Origin Not Reported​

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.​

Asian Indian/Indian Sub-Continent ​

Chinese​

Filipino​

Japanese​

Korean​

Vietnamese​

Other Origin​

Origin Not Reported ​

​Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.​

Native Hawaiian​

Guamanian or Chamorro​

Samoan​

Other Origin​

Origin Not Reported​

Race Not Reported – Select if person did not self-identify a race category or origin.​

Organ Information

Candidate medical urgency status: Indicate the candidate's medical urgency status. If one of the active statuses is selected, the candidate is eligible to appear on a UNet^SM match run. If temporarily inactive is selected, the candidate is non-eligible to appear on the UNet^SM match run. This is a required field.

Active

Temporarily Inactive

Inactive reason: Select the reason the candidate is inactive.

Candidate cannot be contacted

Candidate choice

Candidate for living donor transplant only

Candidate work-up incomplete

COVID-19 Precaution

Inappropriate substance use

Insurance issues

Medical non-compliance

Physician/Surgeon unavailable

Temporarily too sick

Temporarily too well

TX Pending

TX'ed - removal pending UNet data correction

Weight currently inappropriate for transplant

Note: The inactive reason TX'ed - removal pending UNet data correction is only to be used when a transplant center removed the incorrect candidate from Waitlist due to transplant and is waiting for UNOS to correct the data so that the correct candidate can be removed with the right donor ID. Candidates should not be set to inactive for this reason for more than 5 days.

Number of previous VCA - musculoskeletal composite graft segment transplants: Indicate the candidate's number of previous VCA - musculoskeletal composite graft segment transplants. Enter a number between 0–9. This is a required field.

VCA body part(s): Select the VCA organ(s) for the candidate. This field is required.

Chest wall

Composite graft of vascularized muscle, bone, nerve, or skin

Spine axis

Clinical Data

Blood type: Select the candidate's blood type. This is a required field.

Note: A2 is used as shorthand for any blood type A subtype other than A1 (i.e., non-A1, negative for A1). A2B is used as shorthand for any blood type AB subtype other than A1B (i.e., non-A1B, negative for A1B). Policy requires at least two (2) separate blood typings prior to listing. Policy also requires you to review all known available blood type source documents to verify the candidate's blood type.

O

A

B

AB

Z (in Utero Only)

Height: Enter the height of the candidate at the time of listing in the appropriate space, in feet and inches or centimeters. The height must fall between 0 and 7 feet 5 inches or 1 and 225 centimeters. This field is required.

Weight: Enter the weight of the candidate at the time of listing in the appropriate space, in pounds or kilograms. The weight must fall between 0 and 650 pounds or 0 and 295 kilograms. This field is required.

Select any additional organs the candidate may need:

Heart

Heart-lung

Intestine

Kidney

Liver

Lung

Pancreas

Pancreas islets

VCA - abdominal wall

VCA - external male genitalia

VCA - head and neck

VCA - lower limb

VCA - other genitourinary organ

VCA - spleen

VCA - upper limb

VCA - uterus

VCA - vascularized gland

HLA and Unacceptable Antigens

HLA: Indicate the candidate's histocompatibility antigens.

Unacceptable antigens: The unacceptable antigens entered are used to determine the Calculated PRA (CPRA) and to screen candidates from matches for donors with antigens listed as unacceptable. 
Select all of the unacceptable antigens and then click the "Calculate" button for the CPRA score.

Calculated Panel Reactive Antibody (CPRA) is the percentage of deceased donors expected to have one or more of the unacceptable antigens indicated on the waiting list for the candidate. The CPRA is derived from HLA antigen, allele, and epitope genotype frequencies for the different populations in proportion to their representation in the national deceased donor population.

CPRA value used for allocation per OPTN policy: The value rounded to the nearest one-hundredth and displayed with a % symbol. 

Detailed CPRA value: The value displayed as a decimal to 6 digits of precision.

Select all A unacceptable antigens: Select the candidate's A unacceptable antigens, if applicable.

Select all B unacceptable antigens: Select the candidate's B unacceptable antigens, if applicable.

Select BW unacceptable antigen: Select the candidate's BW unacceptable antigen, if applicable.

Select all C unacceptable antigens: Select the candidate's C unacceptable antigens, if applicable.

Select all DR unacceptable antigens: Select the candidate's DR unacceptable antigens, if applicable.

Select all DR 51/52/53 unacceptable antigens: Select the candidate's DR 51, 52 and 53 unacceptable antigens, if applicable.

Select all DQB1 unacceptable antigens: Select the candidate's DQB1 unacceptable antigens, if applicable.

Select all DQA1 unacceptable antigens: Select the candidate's DQA1 unacceptable antigens, if applicable.

Select all DPB1 unacceptable antigens: Select the candidate's DPB1 unacceptable antigens, if applicable.

Select all DPB1 unacceptable epitopes: Select the candidate's DPB1 unacceptable epitopes, if applicable.

Select all DPA1 unacceptable antigens: Select the candidate's DPA1 unacceptable antigens, if applicable.

Infectious Diseases

Accept a Hepatitis B Core antibody positive donor?: Select Yes if the candidate will accept a Hepatitis B core antibody positive donor. If not, select No. This field is required.

Accept an HBV NAT positive donor?: Select Yes if the candidate will accept an HBV NAT positive donor. If not, select No This field is required.

Accept an HCV antibody positive donor?: Select Yes if the candidate will accept an HCV antibody positive donor. If not, select No. This field is required.

Accept an HCV NAT positive donor?: Select Yes if the candidate will accept an HCV NAT positive donor. If not, select No. This field is required.

HOPE Act IRB Research

Is the candidate HIV positive and willing to accept an HIV positive VCA - musculoskeletal composite graft segment?: Select Yes if the candidate is HIV positive and willing to accept an HIV positive VCA - musculoskeletal composite graft segment. If not, select No. This field is required.

Donor Type

Accept DCD donor?: Select Yes if the candidate will accept a DCD (Donation after Circulatory Death) donor. If not, select No. Donation after Circulatory Death (DCD) describes the organ recovery process that may occur following death by irreversible cessation of circulatory and respiratory functions. A DCD donor may also be called a non-heartbeating, asystolic, or donation after cardiac death donor. This field is required.

Donor Characteristics

Minimum acceptable donor age: Enter the minimum donor age that the candidate can accept. The age must fall between 0 and 99 years. This field is required.

Maximum acceptable donor age: Enter the maximum donor age that the candidate can accept. The age must fall between 0 and 99 years. The maximum value must only be entered in months if the minimum value is also entered in months (e.g., you are able enter that you will accept donors from 3 months to 3 years in age, but you may NOT enter that you would accept a donor from 1 year to 36 months in age). This field is required.

Minimum acceptable donor height: Enter the minimum donor height that the candidate can accept in inches (in) or centimeters (cm). The height must fall between 0 to 305 inches, or 0 to 305 centimeters. This field is required.

Maximum acceptable donor height: Enter the maximum donor height that the candidate can accept in inches (in) or centimeters (cm). The height must fall between 0 to 305 inches, or 0 to 305 centimeters. This field is required.

Maximum acceptable donor BMI: Enter maximum donor body mass index (BMI) in kilogram-meter squared (kg/m²) that the candidate can accept. The BMI must fall between 5.0 and 100.0 kg/m².

Acceptable donor birth sex: Select whether the matching donor must be Male, Female, or Either birth sex (male or female).

Additional donor acceptance and/or exclusion criteria to display as informational to OPO: List any additional information for the candidate that will be visible to the OPO, such as if the upper extremities are above/below the elbow, if partial face, skin tone, etc.

Donor Clinical Data

Accept VCA - musculoskeletal composite graft segment if procured by another team?: If the candidate will accept a VCA - musculoskeletal composite graft segment procured by another team, select Yes. If not, select No. This field is required.

Recovery

Maximum nautical miles the organ or recovery team will travel: Enter the maximum miles the candidate's organ or recovery team will travel to obtain an organ. The number must fall between 0 and 9,999 miles. The matching system calculates mileage between the donor hospital and the recipient center based on the hospitals' zip codes. This distance is measured in nautical miles (a measure of flight distance), not in statute miles (a measurement of driving distance). This field is required.

Conversion Table for Nautical and Statute Miles

Nautical Miles	Statute Miles
250	287.7
500	575.4
1000	1150.8
1500	1726.2
2000	2301.6
2500	2876.9

Verify ABO

Select the candidate’s ABO. Policy requires at least two (2) separate blood typings prior to listing. Policy also requires you to review all known available blood type source documents to verify the candidate's blood type.

HIV Verification

Policy requires that a second user must verify:

• The HIV status of the candidate

• The willingness of the candidate to accept an HIV positive organ

Is the candidate HIV positive and willing to accept an HIV positive VCA - musculoskeletal composite graft segment?: Select Yes if the candidate is HIV positive and willing to accept an HIV positive VCA - musculoskeletal composite graft segment.

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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